Returning Patient Forms

Securely complete your patient registration forms for Back In Action Medical Center.

Enter Date of Birth Below *

Please select the option that applies to your primary phone number. *

Cell

Home

Work

Secondary Phone Number

Preferred Contact Method *

Phone

Text

Marital Status *

To be used for provider communication, follow up, patient portal, and practice related material. We DO NOT share email information with other parties. You may choose to remove any time

Employment Status *

Preferred Language *

English

Spanish

Other

Please enter other language if applicable.

Race *

Preferred Pharmacy *

Insurance Information

Primary Insurance Company *

Please enter the name of the policy holder if "other" was selected above.

Name of Policy Holder *

Same as above

Other

Policy Holder's Date of Birth *

Policy Holder's Relationship to Patient *

Self

Mother

Father

Other

If "Other" was selected above please enter the relationship to the policy holder below

Policy Holder's Social Security # (Only required if different than above)

Upload a copy of your insurance card [FRONT]

Upload a copy of your insurance card [BACK]

Please enter the name of your Secondary Insurance Company if applicable

Name of Secondary Policy Holder if applicable

Secondary Group Number if applicable

Secondary Subscriber Number if applicable

In Case of Emergency

I hereby give permission to disclose and discuss any information related to my medical condition(s) with the following listed individual: *

Please enter your relationship with the above listed individual. *

Please enter your emergency contacts phone number. *

Permission to contact: *

Yes

Emergency Contact #2

Please enter your relationship with emergency contact #2

Please enter your emergency contact #2's phone number.

Permission to contact emergency contact #2 *

Yes

Reason for Today's Visit

Please describe symptoms *

Reason for today's visit *

Please report previous treatment received for condition *

Please list other treatment received if not shown above

Please list current medications prescribed by another provider or anything you are taking over the counter. Enter "n/a" if not applicable. *

Please enter the dosage of the medications listed above. Enter "n/a" if not applicable. *

Condition(s) that requires the medications listed above. Enter "n/a" if not applicable. *

Medical History - Please Check All That Apply *

If you selected cancer or other, please elaborate on the condition:

Please list medication allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list supplement allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list food allergies below and the allergic reaction that occurs. Enter "N/A" if not applicable *

Please list other allergies below. Enter "N/A" if not applicable. *

Please select all that apply to your surgical history. *

Please list any other surgical history. Enter "N/A" if not applicable *

Any hospitalizations besides surgery? *

Yes

Mother *

Alive

Deceased

Adopted/Unknown Family History

Father *

Alive

Deceased

Adopted/Unknown Family History

ADD/ADHD *

Mother

Father

Other

None

Please enter the relationship to affected family member if "other" was selected above.

Alcoholism/Substance Abuse *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected above.

Alzheimer's/Dementia *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Arthritis *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected above.

Asthma *

Mother

Father

Other

None

Please list the relationship to affected family member if other was selected above.

Auto Immune Disease (ex: Lupus) *

Mother

Father

Other

None

Please provide the relationship to your family member if other was selected above.

Cancer (please elaborate below if selected) *

Mother

Father

Other

None

Please provide the relationship to the family member if other was selected above.

COPD *

Mother

Father

Other

None

Please input the relationship to the affected family member if other was selected above.

Diabetes *

Mother

Father

Other

None

Please input your relationship to the affected family member if other was selected.

Eczema/Psoriasis *

Mother

Father

Other

None

Please enter your relationship to the affected family member if other was selected.

Heart Disease *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Hemodialysis *

Mother

Father

Other

None

Please enter the relationship to the affected family member if other was selected.

Hepatitis *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected.

High Blood Pressure *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected above.

High Cholesterol *

Mother

Father

Other

None

Please list your relationship to the family member if other was selected above.

Kidney Disease *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected above.

Obesity *

Mother

Father

Other

None

Please list the relationship to the family member if other was selected above.

Parkinson's Disease *

Mother

Father

Other

None

Please input the relationship to your affected family member if other was selected.

Psychiatric Disorder *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected above.

Seizure Disorder *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected.

Stomach or GI Problems *

Mother

Father

Other

None

Please list your relationship to the affected family member if other was selected above.

Stroke/TIA *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected.

Thyroid Problems *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected.

Your Exercise Habits: *

Tobacco Use: *

How many alcoholic beverages do you consume per week? *

How many caffeinated drinks do you consume per day?

Drug Use: *

No history of recreational drug use

Former use of recreational drugs

Current use of recreational drugs

How do you spend most of your time at work? *

Sitting

Standing

Walking

N/A

How labor intensive is your work? *

How many hours do you work per week? *

How would you describe your work environment? *

(Check all that apply)

Allergic/Immunologic *

Hives

Eczema

Hay Fever

N/A

Cardiovascular *

Constitutional *

Weight Loss

Fatigue

Fever

N/A

Endocrine *

Loss of hair

Heat/Cold Intolerance

N/A

Eyes *

Ear, Nose, and Throat *

Gastrointestinal *

Genitourinary *

Hematology/Lymph *

Brusing

Gums Bleed Easily

N/A

Musculoskeletal *

Neurological *

Psychiatric *

Anxiety/Depression

Mood Swings

Difficulty Sleeping

N/A

Respiratory *

Cough Easy

Wheezing

Chills

N/A

Skin *

Rash/Sores

Lesions

Itching/Burning

N/A

Medical Information Release Form

This release of information will remain in effect until terminated by me in writing.

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me, and claims information. This information may be released to: *

Please enter the relationship to the individual you are authorizing the release of information below. *

Select "Do Not Release" below if information is not to be shared with anybody.

Do Not Release

How should we contact you by phone? *

Home

Cell

Work

If unable to reach you: *

You may leave a detailed message

Please leave a message asking me to return your call

Other

If "Other" was selected above please enter details below.

What days are best to reach you? *

What times are best to reach you? *

Morning

Early Afternoon

Late Afternoon

When an appointment is scheduled for you with Michael Carpino or Misty Gaddis at Back in Action/Best Life Primary Care, it is your responsibility to confirm your appointment 24hrs prior to the appointment time. The front desk team will call and or email you to confirm your appointment. In the event you do not answer a voice mail will be left. If you as the patient do not make conformation of your scheduled appointment within 24hrs your appointment will be canceled and rescheduled for a later date. If you have an appointment scheduled and you do not show up, you will be billed a $50.00 no show fee. We understand that circumstances will arise that will result in you having to cancel please give us a courtesy call 24hrs prior to your scheduled time to prevent the no show fee being charged.

We value you as one of our patients and hope you understand why this is a necessary office policy.

Please sign and date below stating your acknowledgement of this policy.

Patients Full Name *

If not patient please enter the name of legal guardian below

Signature (Sign below) *

Clear