• ADULT NEW PATIENT HISTORY FORM

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  • Emergency Contact

  • Insurance

  • The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance not covered by my insurance. I also authorize CNY Family Care or insurance company to release any information required to process claim.

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  • Care Provider

  • ADVANCE DIRECTIVES

  • IMPORTANT: We ask that you bring your physician a copy of any documentation you have available regarding the above advance directives at your first appointment.

  • IMMUNIZATION HISTORY

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  • IMPORTANT: We ask that you bring a copy of your immunization record with you to your first appointment.

  • ALLERGIES

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  • MEDICATIONS

  • HEALTH MAINTENANCE HISTORY

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  • CHILDHOOD ILLNESS

    Indicate if you have had
  • Medical Problems Review

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  • Hospitalizations

  • ASSISTIVE DEVICES

    Please indicate if you currently require any assistive devices.
  • OBSTETRIC/ GYNECOLOGIC HISTORY FOR WOMEN

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  • FAMILY HISTORY MEDICAL ISSUES

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  • SOCIAL HISTORY

  • BARRIERS TO CARE

  • Self-Care Assessment

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  • PERSONAL HABITS

  • I have completed this Adult Intake Form to the best of my ability

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  • Clear
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  • Should be Empty: