Patient Information Last Name: First Name: M.I.: Previous Name (if applicable) Mailing Address: Apt # City/State/Zip: Home Phone: Cell Phone: Work Phone: Email Address: **PHARMACY / LOCATION: Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages: If Voice, Please Select Preferred Number: (Please Select Only One Option) Voice Text Patient Portal Home Cell Work Marital Status: Date of Birth: Sex:

❑ Male ❑ Female Social Security #: Emergency Contact Name: Emergency Contact Phone #: Relationship to Patient:

Responsible Party- If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor Last Name: First Name: Date of Birth: Social Security #: Phone: Address of Person Responsible: City/State/Zip: Relationship to Patient: How did you hear about us? Friends Family Co-worker Insurance Website ER/Urgent Care Internet: ____________________ Specialist Newspaper

Magazine Other _____________________________________________________________ When you are unavailable to answer the phone, may we leave detailed voicemails about your medical treatments, care plan, test results, referrals, and prescriptions? Yes No If yes, on which phone numbers? Home Cell Work

Race (please select): White American Indian or Alaska Native Asian Hispanic Black or African American Native Hawaiian or Pacific Islander Decline Other _______________________________________________________

Ethnicity (please select one): Hispanic or Latino Not Hispanic or Latino Other ___________________________________

Preferred Language (please select one): English Chinese Indian (including Hindi & Tamil) Filipino/Tagalog Spanish Russian Other _________________________________

Primary Medical Insurance Secondary Medical Insurance Ins. Co. Name Ins. Co. Name Policy Holder Name: Policy Holder Name: Policy Holder's Date of Birth: Policy Holder's Date of Birth: Policy Holder's Social Security #: Policy Holder's Social Security #: Patient Relationship to Policy Holder: Patient Relationship to Policy Holder:

Our office uses our online Patient Portal extensively to communicate with our patients. Patients can view lab results, book appointments, request refills, update key information, pay balances, and many other functions via Patient Portal. Be sure you sign up for it.

Patient Registration Form

2545 E. Bidwell St, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

(Phone) 916-983-8868 (Fax) 916-983-8891 www.HealthyLivingPC.com

Your prescriptions may be delayed if we do not have your pharmacy information on file.

*Pharmacy / Location

Please go to next page Page 1 of 3

Name Date of Birth

Comprehensive New Patient Health History Questionnaire

Main reason for today’s visit:

Please list all healthcare providers you see regularly:

PERSONAL MEDICAL HISTORY: Have you ever had any of the following conditions?

Condition Now Past Condition Now Past

Alcohol / Drug abuse Gynecological Conditions (Endometriosis)

Allergy (Hay Fever) ( ) Gynecological Conditions (Fibroids)

Anemia Gynecological Conditions (Other)

Anxiety Hepatitis – Type A | B | C

Arthritis (Rheumatoid) Herpes (cold sore or genital)

Arthritis (Osteoarthritis) High Blood Pressure

Asthma High Cholesterol

Bladder / Kidney Problems Inflammatory Bowel Disease

Blood Clot ( ) Irritable Bowel Syndrome

Cancer ( ) Kidney Disease / Failure

Cataracts Kidney Stones

Chronic Pain ( ) Liver Disease

Colon Polyp Migraine Headaches

Coronary Artery Disease Osteoporosis

Depression Prostate (enlargement)

Diabetes (adult onset) Seizure / Epilepsy

Diabetes (childhood onset) Sleep Apnea

Diverticulosis Stomach Ulcer

Emphysema (COPD) Stroke

Fractures (broken bones) Thyroid (Nodule)

Gallbladder Disease Thyroid High (Overactive) / Hyperthyroidism

Gastroesophageal Reflux (Heartburn/GERD) Thyroid Low (Underactive) / Hypothyroidism

Glaucoma Other ( )

Gout Other ( )

SURGICAL & PROCEDURE HISTORY – Please enter the year of any procedures or surgeries below.

Surgical Procedure Year Surgical Procedure Year

Abdominal surgery ( ) Hysterectomy (partial, ovaries left)

Appendectomy (appendix removal) Hysterectomy (total, including ovaries)

Back surgery Joint Arthroscopy ( )

Biopsy ( ) LEEP (Cervix surgery)

Breast Biopsy Neck Surgery

Breast surgery Ovary Removal

Cataract surgery Sinus Surgery

Coronary Bypass Tonsillectomy

Coronary Stent Tubal ligation

C-Section Urological Surgery

Gallbladder Removal Vascular Surgery ( )

Heart Surgery( ) Vasectomy

Hip Surgery ( ) Other ( )

Please go to next page Page 2 of 3

FAMILY HISTORY

Adopted? No Yes. If adopted, and you do not know your birth family’s history, skip this Family History section.

Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes.* If some siblings are alive and some are deceased use the space to the right to explain further.

Mo

ther

Fat

her

* S

iste

r(s)

* B

roth

er(s

)

Mo

m’s

Mo

m

Mo

m’s

Dad

M

om

’s

Sib

ling

s D

ad’s

Mo

m

Dad

’s

Dad

D

ad’s

Sib

ling

s

Alive Deceased

Age currently or at death

Diseases & Conditions Mo

ther

Fat

her

Sis

ter(

s)

Bro

ther

(s)

Mo

m’s

Mo

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Mo

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Dad

M

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’s

Sib

ling

s D

ad’s

Mo

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Dad

’s

Dad

D

ad’s

Sib

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Other blood relatives (list relationship to

you)

No significant history known

Hypertension – high blood pressure

Hyperlipidemia – high cholesterol

Heart Attack, Angina (Coronary Artery) Disease)

Diabetes Type I (childhood onset)

Diabetes Type II (adult onset)

Osteoporosis

Depression Alcoholism / Drug abuse

Alzheimers

Asthma

Autoimmune Disease

Bleeding or Clotting Disorder

Cancer ( ) Colon Polyp Emphysema (COPD) Genetic Disorder (explain)

Heart Disease (CHF)

Hepatitis B or C

Hypothyroidism / Thyroid Disease

Kidney Disease

Stroke

Sudden Cardiac Death

Other ( )

Other ( )

MEDICATIONS: Please list (or show us your own printed record) all prescription and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc).

Check box if you do not take any prescription or over the counter medications. Check box if you brought a list of your medications (give it to my assistant and don’t write in medications below).

ALLERGIES or intolerance to medications? No known drug allergies

(If yes, to what & what reaction?)

Medication Dose

(e.g. mg/pill) How often?

Medication

Dose (e.g. mg/pill)

How often?

Thank you for taking the time to complete this form Page 3 of 3

IMMUNIZATIONS: I have voluntarily declined all vaccines in the past.

Vaccine Date Vaccine Date Vaccine Date

Hepatitis A Pneumovax (Pneumonia) Whooping Cough (DTaP)

Hepatitis B Prevnar 13 (Pneumonia) Shingrix (shingles)

HPV Tetanus (Td)

Influenza (flu shot) Varicella (Chicken Pox)

HEALTH MAINTENANCE SCREENING TESTS:

Test Date Result Test Date Result

Screening Labs □ Normal □ Abnormal Sigmoidoscopy □ Normal □ Abnormal

Physical Exam □ Normal □ Abnormal Colonoscopy □ Normal □ Abnormal

Endoscopy □ Normal □ Abnormal Stress Test □ Normal □ Abnormal

Women Only

Mammogram □ Normal □ Abnormal Bone Density Test (DEXA) □ Normal □ Abnormal

Pap Smear □ Normal □ Abnormal

Alcohol/Tobacco/Drug Use History:

Alcohol Use

Alcohol Use: Yes Not Currently Never Defer How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 3 or 4 5 or 6 7 or 9 10 or more Patient Refused

How often do you have a drink containing alcohol?

Never Monthly or Less 2-4 times a month 2-3 times a week 4 or more times a week Patient Refused

How often do you have six or more drinks on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily Patient Refused

Drinks/week:

____ Glasses of wine ____ Cans of beer ____ Shots of liquor ____ Standard drinks or equivalent

Tobacco Use Drug Use

Smoke / smoked □ Cigarettes □ E-Cigarettes □ Pipe □ Cigar □ Chewing Tobacco □ Snuff Tobacco □ None

Have you ever used recreational drugs? No Yes

Currently Using:

Used in the past:

Number of uses per week:

Never Smoked

Current smoker: Packs/day: Year Started:

Are you ready to quit? No Yes

Former smoker: Year you quit:

Approximately how many packs/day did you smoke?

Year you start smoking?

SOCIAL HISTORY:

Marital status: single partner married divorced widowed Spouse/partner’s name:

Number of children: Number of grandchildren: Number of great grandchildren:

Education: high school or GED trade school college graduate school other

Occupation: Employer:

If you are not working, you are: retired unemployed on a leave of absence disabled homemaker other

WOMEN’S HEALTH HISTORY:

Total number of pregnancies: Number of births: Number of miscarriages: Number of abortions:

Healthy Living Primary Care 2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 • 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

Phone: (916) 983-8868 Fax: (916) 983-8891

Office Policies

WELCOME TO OUR PRACTICE: We are glad you have selected our office for your healthcare needs. Our care

team includes physicians, mid-levels, and many other supporting staff. We work as a team to provide quality

care to people of all ages. We offer personalized care through the use of the latest in medical information and

diagnostic technology. Developing a strong and long-lasting relationship between the patient and physician is

important to us.

KNOW YOUR INSURANCE PLAN: Under the dynamic changes of the insurance world, it is critical for patients

to understand their own insurance benefits and restrictions. Until your deductible is met, office visits, blood

work and imaging tests are the patient’s responsibility. Preventive lab tests are only limited to cholesterol

panel, complete metabolic panel, complete blood count, thyroid test, and prostate enzyme. Any other tests

are subject to potential out-of-pocket payments, depending on your plan. Preventive visits only cover

screening for high blood pressure, cholesterol, breast exam, Pap smear, vaccinations and physical exam.

Discussion of any medical condition during your preventive visit is subject to an additional charge for a sick

visit.

APPOINTMENTS: One of the goals of this office is to respect our patients’ time by having you in the exam

room at the time of the scheduled appointment as opposed to being in the waiting room. In the event that

you are inadvertently delayed in your arrival for your appointment, every effort will be made to fit you into

the existing schedule. However, there may be times that we will request that you re-schedule your

appointment if we cannot accommodate you.

CANCELLATIONS: If you find that you need to cancel your appointment, please provide the office with 24-

hours’ notice to avoid a $50.00 No-Show/Same-Day cancellation fee via Patient Portal, phone call or voicemail.

We will be glad to reschedule you to a more convenient time.

CHRONIC DISEASE MANAGEMENT PROGRAM (if you qualify): If you have at least two chronic diseases, you

qualify for our Chronic Care Management Program at no charge to you. This program’s goal is to make sure

that your health is well managed. Our designated CCM specialist will review your chart monthly for such

things as preventative care, medication reconciliation, RX refills, and medical management by other

specialists. Patient understands that only the primary care physician can administer this program and that

patient can opt out of the program anytime.

I understand and agree to all the above policies.

Patient’s Name: ____________________________________ Parent’s/Conservator’s Name: _____________________________

Patient’s/Parent’s/Conservator’s Signature: _________________________________________________ Date:_____________

Healthy Living Primary Care

Office Procedures LABS:

• Lab orders are sent to Quest electronically for your convenience. You can go to any Quest without a printed order. If you would like to go to LabCorp, we will print you the lab order.

• If you are given a paper slip at check out, it is important to bring that lab slip with you to the lab.

• You can make appointments online at www.QuestDiagnostics.com to cut down wait time.

• If you have a PPO, most lab tests count toward your deductible. For most insurances, preventive lab tests are limited to cholesterol panel, comprehensive metabolic panel, complete blood count, thyroid test, and prostate enzyme. Please call your insurance if you have questions about cost and coverage.

IMAGING TESTS:

• Call Sutter Imaging to schedule the test and bring in the printed order.

• However, any patient with Covered California and Connected Care needs to go to Mercy Imaging

• If prior authorization is required by your insurance, we will obtain the authorization and you will be contacted through our Patient Portal once this is complete. Depending on the urgency of your exam, prior authorization can take up to 7-10 business days to process.

REFERRALS:

• Please allow up to 7-10 business days to process your referral unless it is medically urgent. You will be notified through our Patient Portal when your referral is done.

• Please make an appointment with the specialist within 30 days because many offices will disregard the referral after 30 days. There is a $25 fee for any repeat referrals.

• All pertinent medical information will be sent with the referral to the specialist. You also have access to your medical record through our Patient Portal if anything additional is needed by the specialist.

• We will do our best to refer you to a specialist within your insurance network. However, it is your responsibility to confirm that the specialist is in your network before receiving services with that office.

TEST RESULT:

• We will always notify you of all test results. If you do not hear from us after 2 weeks, contact us via Patient Portal.

• For routine or preventative lab/tests, our providers will send you the interpretation of the test results through our Patient Portal. Afterward, you will also be able to view your results on Patient Portal.

• If the test result is abnormal and requires an in-depth discussion, we will contact you via Patient Portal to schedule a follow-up appointment.

• For follow-up tests, our provider will discuss the test results with you in detail at your next follow-up appointment.

• If any test result is urgent, you will be contacted by phone.

KNOW YOUR INSURANCE PLAN:

• Under the dynamic changes of the insurance world, it is critical for patients to understand their own insurance benefits and restrictions. Until your deductible is met, office visits and tests are the patient’s responsibility.

URGENT CARE/AFTERHOUR CARE:

• We have multiple providers here daily to take care of your urgent medical needs. You should be able to get an appointment with someone on our care team on the same day if you call early in the day. If you need care after office hours, on-call doctors are available for consultation 24/7. Directions to local urgent care centers are outlined in our voicemail message. Keep in mind that for life threatening emergencies you should call 911.

RX REFILLS:

• Please check for any refills you might need prior to each visit. If you need a prescription refill between visits, please contact your pharmacy and they will send an electronic request to our office. You can also request for medication refill on Patient Portal. Please allow 24 to 48 hours for your prescription to be approved by the physician and processed by our office. However, we are not able to refill narcotic medication without a visit.

I understand and agree to all the above office procedures.

Patient’s Name: ___________________________ Parent’s/Conservator’s Name: _____________________________

Patient’s/Parent’s/Conservator’s Signature: ___________________________________________ Date:_____________

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Healthy Living Primary Care

2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

Phone: (916) 983-8868 Fax: (916) 983-8891

Medication History Consent

By signing below I give permission for this medical office to access my pharmacy benefits data electronically through RxHub. This consent will enable this medical office to: • Determine the pharmacy benefits and drug co pays for a patient’s health plan.

• Check whether a prescribed medication is covered (in formulary) under a patient’s plan.

• Display therapeutic alternatives with preference rank (if available) within a drug class for medications. • Determine if a patient’s health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe

to these pharmacies.

• Download a historic list of all medications prescribed for a patient by any provider. In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub. _________________________________ Patient Name _________________________________ _________________ Patient Signature Date

Healthy Living Primary Care

2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

Phone: (916) 983-8868 Fax: (916) 983-8891

Consent for Text Message Reminder

I hereby give my consent to Healthy Living Primary Care to use SMS Text Messaging at mobile

phone number _______________________ for appointment reminders ONLY. I

understand that I will be provided with the option to confirm or cancel my appointment via text

messaging. However, if I would like to reschedule I will need to contact Healthy Living Primary Care

at 916-983-8868. I also understand that my mobile service provider may charge a SMS text message

fee for any messages sent and/or received from my phone number.

Patient Name: Please print

Signature: Date:

In the event of a Parent/Guardian signing for a minor, please state your relationship:

All patients have the right to change their minds. If you wish to change your reminder option, please

notify reception. If you change your phone number please inform us so that we can update our

records.

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