New Patient Intake

Apex One Wellness

STEP 1 OF 10 Patient Information

Patient Information

Please provide your patient and contact information.

Emergency Contact

Primary Guardian / Caretaker

How Did You Hear About Our Office?

Insurance Portal
Family
Friend
Online / Google
Close to Home / Work

Payment / Insurance Information

Select the applicable payment or insurance option.

Self-Pay
Health Insurance
Work Comp (WC)
Personal Injury (PI)

Subscriber Information

Health Insurance

Additional / Secondary Insurance

Is the patient covered by additional/secondary insurance?

Yes
No

Assignment and Release

On behalf of yourself and any patient whom you are the parent or legal guardian you:

1) certify that the information on this form is accurate and up-to-date,

2) consent to treatment by Apex One Wellness,

3) assign to Apex One Wellness any health care insurance or reimbursement benefits to which you are entitled for the care provided by Apex One Wellness, authorize their payment directly to Apex One Wellness and authorize the use of your signature for this limited purpose,

4) agree to be primarily responsible for all charges owed to Apex One Wellness (other than those included in any pre-paid offer), including attorney fees, court costs, and other expenses of collection,

5) consent to Apex One Wellness releasing any “protected health information,” as defined by federal HIPAA regulations, for the purposes allowed by law,

6) acknowledge receipt of Apex One Wellness’s Notice of Privacy Practices.

All services are payable at the time they are rendered (co-pays, deductibles, co-insurance, out of pocket [private pay]). You will be given all necessary forms to submit to your insurance for reimbursement if services are covered (if out of network).

There is a $125.00 fee for appointments NOT cancelled 24 hours in advance for NEW PATIENTS. There is a $75.00 fee for appointments NOT cancelled 24 hours in advance for ESTABLISHED PATIENTS. There is a $25.00 fee for returned checks.

Preferred Pharmacy & Primary Complaint

Preferred Pharmacy

Prescription Refill Policy

Please do not wait until your last pill to call for a refill. There is a 24-48 hour turn around for prescription refills. If you have not seen the physician in six (6) months, the prescription will be denied. If the prescription is considered a controlled substance, you are required by law to be physically seen in office once every three (3) months for prescriptions to be authorized. More frequent visits may be requested at provider’s discretion.

Primary Complaint

When Did Your Symptoms First Appear?

In the Past Few Days
In the Last 30 Days
In the Last Year
In the Last 2 Years
In the Last 5 Years
More Than 5 Years Ago

What Do You Think Caused This Problem?

Nothing
Injury
Exercise
Heavy Lifting
Surgery
Injury at Work
Motor Vehicle Accident
Multiple Health / Medical Problems
Assault
Trauma

Since It Began, How Has the Condition Changed?

Improving
Worsening
Staying the Same

Pain Severity

How Often Do You Have the Pain?

Constantly
Comes and Goes
Infrequently
Daily
Weekly
Monthly

When Is Your Pain at Its Worst?

Mornings
During the Day
Evenings
Middle of the Night
Pain Location / Type Key:

N = Numbness    S = Stabbing    B = Burning    P = Pins and Needles    A = Aching    T = Throbbing

Type of Pain & Daily Living

Type of Pain

Check all that describe your pain.

Interference with Daily Living

Mark all activities that your condition interferes with.

Prior Treatments & Diagnostic Tests

Prior Treatments

New Conditions in the Past Three Months

Diagnostic Tests and Imaging

Past Medical & Surgical History

Past Medical History

Pregnancy

Allergies

Surgical History

Medications and Supplements

Please list any medications, supplements, or over-the-counter substances you are currently taking.

Family Medical History

Please indicate if any relatives have had the following conditions. Specify maternal (mother's side) or paternal (father's side) for grandparents.

I HAVE NO SIGNIFICANT FAMILY HISTORY
I AM ADOPTED (No Medical History Available)
Arthritis
Mother
Father
Grandmother
Grandfather
Asthma
Mother
Father
Grandmother
Grandfather
Autoimmune Disease
Mother
Father
Grandmother
Grandfather
Cancer
Mother
Father
Grandmother
Grandfather
Connective Tissue Disease
Mother
Father
Grandmother
Grandfather
Diabetes
Mother
Father
Grandmother
Grandfather
Heart Disease
Mother
Father
Grandmother
Grandfather
High Blood Pressure
Mother
Father
Grandmother
Grandfather
Kidney Disease
Mother
Father
Grandmother
Grandfather
Thyroid Disease
Mother
Father
Grandmother
Grandfather
Tuberculosis
Mother
Father
Grandmother
Grandfather
Bleeding Disorder
Mother
Father
Grandmother
Grandfather
Heart Attack
Mother
Father
Grandmother
Grandfather
Stroke
Mother
Father
Grandmother
Grandfather

Social History

Tobacco / Smoke / Vape Products

Cigarettes
Chew
Vaping
Cigars

Illegal Drug Use

Review of Systems

Please mark the symptoms that you currently suffer from. Diagnosed conditions or diseases should be noted under Past Medical History.

Additional Concerns

Final Review

Please review your answers using the Back button before submitting.