Online Forms

Align Health offers our patient form(s) online so they can be completed in the convenience of your own home or office.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Patient information

Patient name:

Age:

SS # or SIN:

Date of Birth:

Gender:MaleFemale

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Patient information

Work Phone:

Cell Phone:

Civil status:

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Patient Address:

City:

State:

Zip:

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Spouse or Patient's Guardian Name:

Spouse's Phone Number:

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Person to contact in case of an emergency:

Phone Number:

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Whom may we thank for referring you?:

In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence:
YesNo

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Responsible Party

Person responsible for this account:

Relationship to Patient:

Date of Birth:

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Responsible Party

Address:

Home Phone:

Cell Phone:

Email:

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Do you have medical insurance?:

Name of the insured:

Relationship to patient:

Date of Birth:

Name of employer:

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ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Align Health/Jerry Ejuwa DC/Jason Kouri MD as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under.

I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policies).

I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments
that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider.

A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

Type patient name:

Enter your email:

Type guardian name if applicable:

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Health History

Chief complaint:

History of Present illness

Location:

Quality:

Severity:

Duration:

Timing:

Context:

Associated Signs/Symptoms:

Modifying Factors:

Have you had previous episodes?
YesNo

How long ago did you have this problem?

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Past Medical History

(Have you ever had the following: (circle “yes” or “no”/ leave blank if you are uncertain.)

Measies:

Mumps:

Chicken Pox:

Whooping Cough:

Scarlet Fever:

Diphtheria:

Small pox:

Pneumonia:

Rheumatic Fever:

Arthritis:

Venereal Disease:

Anemia:

Bladder Infection:

Epilepsy:

Migraine Headaches:

Tuberculosis:

Diabetes:

Cancer:

Polio:

Glaucoma:

Hernia:

Blood or Plasma Transfusion:

Back Trouble:

High Blood Pressure:

Low Blood Pressure:

Date of Last Chest X-Ray:

Asthma:

Hives of Eczema:

AIDS & HIV:

Infectious Mono:

Bronchitis:

Mitral Valve Prolepses:

Stroke:

Hepatitis:

Ulcer:

Kidney Disease:

Thyroid Disease:

Bleeding Tendency:

Any Other Disease:

Please list:

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Previous Hospitalizations/Surgeries/Serious Illnesses:

When?

Hospital, City, State

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Medication: (include nonprescription)

Have you ever taken Fen-Phen/Redux?
YesNo

Are you taking any medications (prescription or over the counter) for acid indigestion?

What type?

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Patient Social History:

Marital Status:

Use of Alcohol:

Use of Tobacco:

Use of Drugs:

Frequency:

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Family Medical History

Father

Age:

Father disease:

If Deceased, Cause Of Death:

Mother

Age:

Mother disease:

If Deceased, Cause Of Death:

Siblings

Age:

Siblings disease:

If Deceased, Cause Of Death:

Spouse

Age:

Spouse disease:

If Deceased, Cause Of Death:

Children

Age:

Children disease:

If Deceased, Cause Of Death:

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Indicate which of the below you have experienced in the last 1-2 months

1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

Eyes/Ears/Nose/Throat/Respiratory Muscular/Skeletal

Asthma:

Stuffy Nose:

Hay Fever:

Sore throat:

Chronic Cough:

Chest Congestion:

Frequent Sneezing:

Itchy/Watery Eyes:

Drainage:

Earache or Ear Infection:

Itching:

Hoarseness:

Shortness of Breath:

Wheezing:

Muscular/Skeletal

Muscle Aches:

Fibromyalgia:

Arthritis:

Joint Pain:

Low Back Pain:

Neck Pain:

Wrist/Hand Pain:

Elbow Pain:

Shoulder Pain:

Hip Pain:

Knee Pain:

Ankle/Foot Pain:

Pain b/t shoulder blades:

Neurological

Headaches:

Migraines:

Dizziness:

Numbness:

Tingling:

Pins/needles in hands or feet:

General

Fatigue:

Malaise:

Weakness, tiredness:

Lightheadedness:

Irritability:

Constipation:

Diarrhea:

Feeling foggy:

Forgetfulness:

[cf7mls_step cf7mls_step-17 "Back" "Next" "Step 18"]To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

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Or if you would like, you can Download & Print Form, remember to carry it with you when paying us a visit

If you do not already have AdobeReader® installed on your computer, Click Here to download.
Download the necessary form(s), print it out and fill in the required information.
Fax us your printed and completed form(s) or bring it with you to your appointment.

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Give us a Call

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New Patient Health History Form - Required

Patient information

Patient information

Responsible Party

Responsible Party

Health History

History of Present illness

Past Medical History

Patient Social History:

Family Medical History

Father

Mother

Siblings

Spouse

Children

Indicate which of the below you have experienced in the last 1-2 months

Eyes/Ears/Nose/Throat/Respiratory Muscular/Skeletal

Muscular/Skeletal

Neurological

General

Visit our Location

Give us a Call

Send us a Message

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