New Patients - Live Well Medical Clinic & Spa

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Home
About Live Well
Our Services
Meet the Providers
Locations
New Patients
Resources & Health Blog
FAQs
Contact

New Patients

Our new patient intake form helps us get to know you before your first visit
so we can make the most of your time. It covers your health history, current concerns, and any goals you have for your care.
It’s quick to complete and helps us create a more personalized, efficient experience from the start.

Live Well Medical - New Patient Intake Form

Please complete all entries. Live Well Medical Clinic & Spa - Baxter & Monterey, TN

Step 1 of 5

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PLEASE COMPLETE ALL SECTIONS

Live Well Medical Clinic & Spa | Baxter & Monterey, TN

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Social Security Number

Phone Number(Required)

Email Address(Required)

Address

City

State

Zip Code

Marital Status

Single

Married

Spouse's Name

Spouse Phone Number

Emergency Contact(Required)

Relationship(Required)

Emergency Contact Phone Number(Required)

Insurance Information

Do you have insurance?(Required)

Yes

No

Primary Card Holder

Self

Spouse

Parent

Other

Other (Primary Card Holder)

Primary Policy Holder Name

Primary Insurance Company

Primary ID Number

Primary Group Number

Do you have secondary insurance?

Yes

No

Secondary Card Holder

Self

Spouse

Parent

Other

Other (Secondary Card Holder)

Secondary Policy Holder Name

Secondary Insurance Company

Secondary ID Number

Secondary Group Number

Payment Policies: You are financially responsible for anything insurance does not cover. All copays are due at each visit.

Prescription Policy

Pharmacy Name

Pharmacy Phone Number

Patient Signature(Required)

Type your full legal name as your signature

Date(Required)

MM slash DD slash YYYY

Patient Medical History

Allergies

None/Known Allergies

Adhesive Tape

Anesthesia

Aspirin

Codeine

Dairy Products

Iodine/Shellfish/Contrast

Latex

Morphine

Penicillin

Do you drink alcohol?

Yes - Daily

Yes - Weekly

Yes - Infrequently

Yes - Recovering Alcoholic

No

Do you smoke?

Yes

No

Packs per day (if smoker)

How many years smoked?

Former smoker

Yes

No

What year did you quit?

Do you drink caffeine?

Yes - Daily

Yes - Weekly

Yes - Infrequently

No

Surgical History

Please list any hospitalizations, surgeries, fractures or major illnesses

Medical History - Have you ever had any of the following?

None of the problems listed

Allergies

Anemia

Arthritis conditions

Arterial fibrillation

Asthma

Bleeding problems

BPH

CAD (coronary artery disease)

Cancer

Cardiac arrest

Celiac disease

Chest pain

Chronic fatigue syndrome

Congestive heart failure

Depression

Diabetes

Drug/alcohol abuse

Erectile dysfunction

Fibromyalgia

GERD

Heart disease

Hyperinsulinemia

Hyperlipidemia

Hypertension

Hypogonadism (male)

Hypothyroidism

Infection problems

Insomnia

Irritable bowel syndrome

Kidney problems

Menopause

Migraines/headaches

Neuropathy

Onychomycosis

Organ injury

Osteoporosis

Pulmonary embolism

Seizure disorders

Shortness of breath

Sinus conditions

Stroke

Syndrome X

Tremors

Wheat allergy

Medications

List any medications currently taking (include over the counter). Include: Medication, Dosage, Prescribing Doctor

Recreational drug use

Yes

No

If yes, what type?

Former drug user

Yes

No

If yes, what type?

Colonoscopy

Yes

No

Where (Colonoscopy)?

Year (Colonoscopy)

Cologuard

Yes

No

Mammogram

Yes

No

Where (Mammogram)?

Year (Mammogram)

Pap Smear Year

Last menstrual cycle

Hysterectomy

Yes

No

Hysterectomy Type (Total or Partial) and When

Family History Details

Please specify which family member for each condition marked above

Family History - Mark which apply

Cancer

Arthritis

High Blood Pressure

Thyroid disorder

Diabetes

Heart issues/diseases

Stroke

Autoimmune disorder

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. By signing, you acknowledge you have reviewed our notice. You consent to our use and disclosure of your protected healthcare information for treatment, payment, or healthcare operations. You have the right to revoke this consent in writing at any time.

May we leave a message on your answering machine at home or on your cell phone?(Required)

Yes

No

May we discuss your medical condition with any member of your family?(Required)

Yes

No

If yes, please name the members allowed

Print Name(Required)

Full legal name signing this consent

Signature(Required)

Type your full legal name as your signature

Date(Required)

MM slash DD slash YYYY

Live Well Medical, Baxter

Office Hours: Mon-Thur 8am-5pm
Closed daily 12-1pm for lunch.

LW Main cropped

Thoughtful primary care in Monterey and Baxter, Tennessee.

Monterey Office: 931-839-6642

Baxter Office: 931-650-5588

Fax Number: 757 695 3421

Live Well Medical, Monterey

Office Hours: Mon-Thur 8am-4pm
Closed daily 12-1pm for lunch.

© 2026 Live Well Medical Clinic & Spa. All Rights Reserved. Site design by The Spinbird Group.

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