Intake Form for Health Insurance Advisory

Please complete the information below. Better Health Advisors complies with all government privacy standards, and your health and demographic information is kept private and confidential.

Demographic Information

Name:
DOB:
Marital Status:
Cell Phone:  
Home Phone:
Office Phone:
Address (where client lives & insurance bills):
Fax:
Email:
Birthplace:
Citizenship:
Primary Contact Name:
Primary Contact Phone Number:

Medical Insurance

Insurance Provider:
Policy Holder:
Group Number:
Issuer:
ID Number:
Health Proxy Number:
Health Proxy Cell Phone:

Personal Health History

Main medical concerns/complaints:

History Of Health Care Professionals
(Medical And Psychiatric)

Please list here: Name & affiliation, reason for seeing & notes:
Have you ever had surgery or an in-patient hospitalization stay?
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers:
Allergies to medications:
Insurance Card (front and back):
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