Patient Information
Insurance Information

Primary Insurance

$

Secondary Insurance

$
Patient Responsibilities Notification
Patient Disclosure Authorization

Christian Family Medicine Inc. has provided me notification of their Privacy Practice for protected health information.  I authorize Christian Family Medicine, Inc. the release of information including the diagnosis, records; examination rendered to me and claims information.

This Release of Information will remain in effect until terminated by me in writing.

Health History
Medication Dose How Often?

Immunization Date

Medical History

Please indicate if you have had the following diseases and let us know if the condition is Current or Not-Current. In the comment box at the bottom, list family members who have had these conditions and whether the condition caused the person's death. When choosing "myself" for having any of the conditions below, choose either "Myself C," meaning you currently have the condition or "Myself P," meaning you had the condition in the past, but no longer have it now.

Surgical & Procedure History

Please check if you have had the surgery or procedure listed.

Health Issues
Packs per day: # of years:
Quit date: Approx packs/day: # years smoked:
Other Information

Social Documentation

Socioeconomic

Medical Forms