PATIENT PROFILE and CONSENTS

Name:									Today’s Date:
Sex:
Date of Birth:
Cell phone:
Email Address:
Home phone:
Work/Other phone:
Home Address/City/State/ZIP:
Employer:
Employer Address/City/State/ZIP:
Occupation/Profession:

Name of Responsible Party if other than patient:
Patient relationship to responsible party:
Street Address/City/State/ZIP:
Date of Birth:
Sex:
Primary phone:
Secondary phone:
Work/Other phone:
Employer:
Address:

Preferred pharmacy name, street address, and zip. IMPORTANT to include zip code.

Dr. Overkamp is not taking new primary care patients at this time.

Next of Kin or Emergency Contact Name:
Relation to patient:
Phone:
Street Address/City/State/ZIP:

Main reason you are coming for this first visit:

What would make this a successful visit for you today?

What do you love doing?

What is your life purpose or purposes?

Medical History

Please place an X next to any problems you’ve had. Then fill out the rest of the row, as in the sample. Use blank rows or extra space for conditions you’ve had that are not in the list.

CONDITION	INCLUSIVE DATES	SEVERITY	EXPLANATION	
Sample: Asthma X	September 1963 to present	moderate	allergic to animal dander, tree and weed pollen, worse in spring and fall	
Anxiety				
Asthma				
Arthritis				
Blood Clots				
Cancer				
Depression				
Emotional Abuse				
Physical Abuse				
Sexual Abuse				
Female diseases, specifically:				
Head Injury				
Headaches				
Heart Problems				
High Blood Pressure				
Male health problems, specifically:				
Seizures				
Stroke				
Thyroid Disease				

				

Surgeries and Hospitalizations

Surgery/Hospitilization	Reason	Dates	Complications	Outcome	
Sample: nasal polypectomy	obstructive sleep apnea	January 10, 2019	none	excellent, no more OSA	
Sample: left knee replacement	advanced osteoarthritis	01.10.2019-01.13.2019	none	fine. Did 6 weeks of PT post surgery.	
Sample: cesarean birth	failure to progress	02.05.2020-02.09.2020	postpartum hemorrhage	good but still having problems with anemia	

					

					

Women

				
My last normal menstrual period began on (give date):	It lasted for the following number of days:	Length of my cycles in days (from day 1 of one month to day 1 of the next month):	Normal for me is:	
I have the the following problems with my period: (use boxes to the right)				
Number of times I have been pregnant:				
Childbirth (child’s name if you want to share it)	Date	Vaginal or Cesarean	Complications	
#1				
#2				
#3				
#4				
	Date	Date	Date	
Miscarriage				
	Date	Date	Date	
Abortion				
	Age			
I had my first period at the following age:				
I reached menopause at the following age:				
I am using the following forms of contraception:				

Medications AND Supplements

Please list all meds and supplements you are currently taking, whether daily or less often.

Name	Dose	Dosing	Comment/Constituents	
sample: Claritin	10 mg tablet	1 tablet every morning	loratadine. as needed during peak Spring and Fall allergy seasons	
sample: Christopher’s Lung and Bronchial Formula	5 drops	twice daily	marshmallow root, mullein leaf, chickweed herb, lobelia herb, lungwort herb, pleurisy root in glycerine and distilled water	
sample: Forest & Meadow Lobelia inflata herbal extract	5-20 drops	10 drops in water 2 times daily and as needed for anxiety but no more than 50 drops daily	Lobelia inflata herb in cane alcohol 65%, distilled water, and raw apple cider vinegar. 1.5 dry herb to menstruum ratio	

				

				

				

				

				

Allergies
Please list all drug, environmental (like pollen, for example), food, and supplement allergies. Please list one allergy per row.

List allergens below	Date or, if unknown, approximate date allergy was noted	Type of reaction: for example, rash, vomiting, sneezing, anaphylaxis	Is the allergy mild, moderate, or severe?	Treatment?	
sample: cat dander	early childhood	asthma	moderate	albuterol inhaler as needed, about 4x/year	

					

					

					

Family History. List family members who have had the following:

	Type	Family Member	Family Member	Family Member	
Cancer					
Diabetes					
Depression					
Suicide attempt					
Heart problems					
Thyroid problems					
Stroke					

Health Risks

Risk Category	Current Type and Amount	Current Frequency and Duration	Past Type and Amount	Past Frequency	Most Recent Quit Date	
sample: tobacco	cigarettes, 1.5 packs	daily, for 20 years total	2 packs	daily, for 2 years total	05.01.2020, restarted 05.15.2020	
sample: alcohol	beer, 1 6-pack	once weekly for 1 year	1 6-pack	4 times weekly for 20 years	none	
sample: marijuana	6 truffles	daily for 4 years	5 joints	daily for 10 years	none	
tobacco						
						
alcohol						
						
street drug						
						
street drug						

Safety

Issue	Yes	No	Does not apply/Comment	
I always wear a seatbelt when riding in a vehicle.				
My passengers always wear seatbelts when I am operating a vehicle.				
I always wear a helmet on a bicycle or motorcycle.				
I have firearms in my home.				
They are kept locked up.				
They are kept unloaded except when in use.				
I think I may have risk of sexually transmitted infections.				
I feel safe at home.				
I feel safe at school.				
I feel safe at work.				
My home life supports me.				

Health Enhancers

	No	Yes/Type	Duration/Intensity	
I engage in daily continuous exercise.				
	No	Yes	Examples	
I use the foods I eat to help improve my health.				
I actively promote my mental health.				
I actively promote my spiritual health.				
	1	2	3	
I have the following health goals:				

HIPAA Disclosure

Do you want us to notify someone for you in case of emergency?

You are NOT REQUIRED to fill out, sign, and date this HIPAA disclosure form.
If you do, we will release information to the person(s) listed here in case of emergency. A separate form is required for specific releases to other medical entities. Please request that form at our front desk if you need one. It is called a Release of Information form.

I, the patient, hereby authorize the doctor listed above to release my medical information
(appointments, lab/x-ray results, diagnoses, treatments, medications, surgeries, etc.) in person and via postal mail, telephone, fax, or email to the following family members or other trusted persons:

Name:
DOB:
Relationship:
Primary phone:
Street/City/State/ZIP:
Email address:

Name:
DOB:
Relationship:
Primary phone:
Street/City/State/ZIP:
Email address:
*Patient Signature (parent or guardian if minor patient):
*Printed name and Date:

CONSENT FOR MEDICAL TREATMENT
CONSENT TO OFFICE POLICIES
CONSENT TO ACCESS PHI
(I must have signed consent before I see you.)

Medical Treatment Consent
I voluntarily consent to medical treatment and diagnostic procedures provided by Susan M. Overkamp, DO, and associated physicians, clinicians and all other personnel. I consent to the testing for infectious and other diseases as deemed advisable by my physician. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees, express or implied, have been made regarding the results of treatments, tests, or examinations.

The undersigned, as patient or guardian of patient, authorizes Susan M. Overkamp, DO,  to medically or surgically manage the treatment of the patient and provide treatment deemed necessary for the benefit of the patient.

Consent to Office Policies
I have reviewed and will comply with office policies.

Consent to Access PHI
The “Notice of Privacy Practices” provides information about how Susan M. Overkamp, DO, may use and disclose protected health information (PHI) about me. I understand that I have the right to review the notice before signing this consent. As provided in the notice, the terms of the notice may change. If the notice is changed, I may obtain a revised copy by request.

I have the right to request that Susan M. Overkamp, DO, restrict how protected health information about me is used or disclosed for treatment, payment, or health care operations. Susan M. Overkamp, DO, is not required to agree to any such restrictions, but if the practice does agree, it is bound by our agreement.

By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment, or health care operations. I have the right to revoke this consent, in writing, except where Susan M. Overkamp, DO, has already made disclosures in reliance on my prior consent.

Be sure to DO ALL THREE THINGS: sign (or e-sign), then print your name, then write today’s date. Thank you!

*Patient Signature:

*Printed name:

*Date: