Patient Forms

Ahava Healthcare
Jody Amazon, DSc APRN

2160 Fountain Drive #220, Snellville,GA 30078
(P) 678-336-9102 (P) 678-336-9300 (F) 770-674-8563
Kristina Thompson – Practice Manager
Kthompson.ahava@gmail.com

Legal name

First

Last

MI

Social Security

Email

Marital Status

Single
Married
Divorced
Widow/ Widower

Employment Status

Retired
Disabled
Employed

Primary Insurance

ID#

Group #

Secondary Insurance

ID#

Group #

Name of physician/person that referred you

Address

Is patient in an assisted living facility, personal care home or nursing home?

If yes, what is the name of the facility?

Name

Relationship to patient

Power of Attorney?

Yes
No

(Please provide a copy of the power of attorney for the chart)

Name

Relationship to patient

Pharmacy Name

Pharmacy Address

Pharmacy Name

Pharmacy Address

Name

First

Last

MI

Age

Referred by

Name & phone number of Primary Care Physician

Spouse’s Name

Years Married

# of Children

# of Grandchildren

Child Name

Where were you born and raised ?

Where do you currently reside?

Occupation

Retired

Yes
No

Year retired

Do you have special living needs?

Yes
No

If yes, please explain:

Are you disabled?

Yes
No

If yes, please describe:

Reason for visit

Allergies

Do you have a memory problem?

Yes
No

If yes, please explain

Do you smoke?

Yes
No

Packs per day?

If you quit, when did you stop?

Do you have a Psychiatric History?

Yes
No

If yes, please describe

Do you drink alcohol?

Yes
No

If yes, how often?

If you quit, when did you stop?

Does your family have any psychiatric history?

Yes
No

If yes, please explain

Alcoholism

Yes
No