If you are unsure or do not have the information, you may input N/A or “0” and move to the next section. 123456 Patient Information and ConsentTitle*Mr.Mrs.Ms.Sr.Jr.Dr.M.D.PhDEsq.Hon.Rt. Hon.Prof.Rev.Name* First Middle Initial Last Social Security Number Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Ethnicity*Select OneAmerican Indian or Alaskan NativeBlack or African AmericanAsian/Pacific IslanderSouth AsianHispanic/Latin AmericanWhite/CaucasianNon Caucasian/OtherHealth risk may vary depending on ethnicityMarital StatusSelect OneSingleMarriedWidowedAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email Address* Employer*Select OneB2BBellevue PoliceBoulder CityBoulder City Fire DepartmentBoulder City Police DepartmentBureau of Land ManagementCentral Lyon County Fire/DaytonChurchill CountyChurchill County SheriffCity of CarlinCity of Reno Fire DepartmentCity of Reno Police DepartmentCity of Sparks Blood DrawCity of Sparks Fire DepartmentCity of Sparks Police DepartmentCity of Sparks OtherClick BondEast Fork Fire and Paramedic DistrictElko County Fire Protection DistrictElko CountyElko County SheriffElko Fire DepartmentElko Police DepartmentEly Fire DepartmentEsmeralda CountyEureka SheriffExecutive PhysicalHayward Fire DepartmentHayward Police DepartmentHumboldt County SheriffLander County SheriffLincoln County SheriffLovelock Police DepartmentLyon County SheriffMason Valley Fire Protection DistrictMineral County Fire DepartmentMineral County SheriffMount Charleston Fire DepartmentNorth Lake Tahoe Fire Protection DistrictNorth Lyon County Protection DistrictNye County SheriffOklahoma City PDPahrump Valley Fire DepartmentPershing County SheriffPrescott Police DepartmentPrivate IndividualsRobb WolfSnohomish County Sheriff’s OfficeStorey County Fire DepartmentStorey County Sheriff DepartmentTahoe Douglas Fire Protection DistrictThe City of ElkoTrainTrainer – Lafayette INUniversity of Nevada RenoWest Lafayette Police DepartmentWest Wendover City Fire DepartmentWest Wendover City Police DepartmentWhite Pine County Fire Protection DistrictWhite Pine County SheriffWinnemucca Police DepartmentYerington Police DepartmentIf employer is not listing, please select Private IndividualOccupation Years in OccupationWork Phone*Spouse Name Spouse/Parents' Employer Spouse's Work PhoneInsurance InformationPrimary Insurance Name of Insurance Company Employer Name Name of Guarantor Member ID Group Number Secondary Insurance BiometricsHeight (feet)*Select an option1'2'3'4'5'6'7'Height (inches)*Select an option0"1"2"3"4"5"6"7"8"9"10"11"12"Weight (pounds)*Select an Option60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398399400Blood Pressure Systolic (upper number)*Select an Option404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250Blood Pressure Diastolic (lower number)*Select an Option404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250Waist Measurement (measure at belly button)Select an option25"26"27"28"29"30"31"32"33"34"35"36"37"38"39"40"41"42"43"44"45"46"47"48"49"50"51"52"53"54"55"56"57"58"59"60"CholesterolHDLLDLTriglyceridesGlucose Health HistoryCurrent Personal Health ConditionsHealth Conditions*Have you ever been diagnosed with the following by a medical professional? (Check the boxes that apply to you) None High Blood Pressure (Hypertension) Coronary Heart Disease (CHD) Abdominal Aortic Aneurysm (AAA) Metabolic Syndrome Alzheimer’s / Dementia Rheumatoid Arthritis, Lupus, Psoriasis, or HIV Transient Ischemic Attack (TIA) Peripheral Artery Disease (PAD) Heart Attack (MI) Congestive Heart Failure (CHF) Stroke Obesity (BMI over 30) Autoimmune Disease Cancer Depression Chronic Kidney Disease (CKD) Chronic Inflammatory Conditions Familial Hypercholesterolemia Bypass Graft, Revascularization, Stent Chronic Pulmonary Obstructive Disease (COPD) Insulin Resistance Thyroid Problems Hx. Premature Menopause Hx. Eclampsia Gout Other Diabetic HistoryDo you have Type 2 Diabetes (DM2)?* Yes No Have you had Type 2 Diabetes 10 years or more? Yes No Do you have Type 1 Diabetes (DM1)?* Yes No Have you had Type 1 Diabetes 20 years or more? Yes No Tobacco use:*NoYesPastAre you currently taking medications/treatment for any of the following conditions?* None High Blood Pressure (HTN) High Blood Sugar High Cholesterol Low HDL Cholesterol High Triglycerides Aspirin Therapy (ASA) Statin Therapy Blood Thinners Depression / Anxiety Tobacco Cessation Familial Hypercholesterolemia (FH) AllergiesPlease list all of your allergies (medication, food, seasonal, etc.) Prescription MedicationsPlease list all of the prescription medications you currently take / Dosage Family HistoryDid your father or a brother develop coronary artery disease or have a heart attack before the age of 55?* Yes No Did your mother or a sister develop coronary artery disease or have a heart attack before the age of 65?* Yes No Is there a history of DM2 (Type 2 Diabetes) in your family?* Yes No PreventionPreventative Health:Please list date of last exam as applicableAnnual Wellness Exam MM slash DD slash YYYY Colonoscopy MM slash DD slash YYYY PAP Smear (Female) MM slash DD slash YYYY Mammogram (Female) MM slash DD slash YYYY Prostate (Male) MM slash DD slash YYYY Dental Exam MM slash DD slash YYYY Eye Exam MM slash DD slash YYYY Mental HealthDo you find yourself experiencing less enjoyment in the things you used to like doing such as sex, hobbies, or social activities?* Yes No Have there been any distinct changes in your sleep, energy, appetite, mood, or sex drive?* Yes No Do you have feelings of sadness, tearfulness, emptiness, or hopelessness?* Yes No Do you find yourself using coping mechanisms to get through the day, which may include alcohol or drugs, sex, gambling, and/or food?* Yes No Do you have frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts, or suicide?* Yes No Are there areas of your life that you desire to improve but feel stuck or unmotivated to pursue them?* Yes No AuthorizationAuthorization*AUTHORIZATION: I hereby consent to and authorize the treating physician, associated personnel, and any other consulting physician called in by the above, to assess or provide first aid and to render medical treatment and health care services to the patient named on this form. I further consent to and authorize procedures or services which may be deemed necessary by said designated or consulting physician. I have been given no guarantee and rely on none as to the result of any assessment, first aid, treatment, or examinations. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of any assessment, first aid, diagnostic, medical, surgical, or therapeutic treatments, procedures, or examinations. I hereby authorize the physicians and staff involved in SpecialtyHealth’s Wellness and Prevention Program to utilize my medical information obtained through the Wellness and Prevention Program for the purpose of research. Research may include individual case studies and/or compilations of group/population data, which may be published and/or presented in lectures. All personal and medical information will be kept confidential. A personal ID will be assigned to each individual participant to protect his/her privacy. ACKNOWLEDGEMENT OF RECEIPT: I have received, or I have been provided the opportunity to receive a copy of the “Notice of Privacy Practices” that explains when, where, and why my confidential health information may be used or shared. I acknowledge that SpecialtyHealth Clinic, the physicians, the nurses, and other SpecialtyHealth staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill, and for issues that concern SpecialtyHealth’s operations and responsibilities. I further acknowledge that I understand that if I have any questions regarding this Notice or wish to file a complaint, I may contact the SpecialtyHealth Privacy Officer in writing. I also understand that no other staff member, physician, nurse, or any other person is authorized to accept a request to exercise my rights but the Privacy Officer for SpecialtyHealth Clinic. Notice of Privacy Practices Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please signify your acknowledgement with your signature beneath the following statement (Release of Information to Someone Designated by The Patient): Release of Information to Someone Designated by the Patient According to the HIPAA compliance for Protected Health Information (PHI), it is necessary to provide SpecialtyHealth Clinic with name(s) of the following individual(s) with whom they may share my protected health information (PHI). It is with my informed consent that these individuals are able to speak with, be given written prescriptions and orders for procecure(s) and discuss health care; options if I am unable to do so. It is also my understanding that I may revoke this consent at any time; as long as the revocation is in writing with a signature, effective date and is received at the office of SpecialtyHealth. SpecialtyHealth will not disclose my medical information to any person or entity unless I specifically authorize such disclosure in writing or SpecialtyHealth is required by law to make such disclosure. I agree to the authorizationDesignated Individual(s) Authorized to receive my Personal Health Information (PHI):Please include name and relationship to the patientUpload your physical Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 32 MB. HiddenFor administrative use only: HiddenExportStatusWSHiddenExportDate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.