Language
English (US)
Spanish (Latin America)
Clinic Date
-
Month
-
Day
Year
Date
Consents
Consent
*
Yes
No
I give staff/volunteers at Clinic with a Heart permission to treat me or my minor child.
I understand that I may have 3 medical visits every calendar year.
I understand that if I am prescribed medicine, it will be from a limited list of available medications and will be for a maximum of a 90-day supply.
I understand that Clinic with a Heart does not prescribe narcotics or controlled substances.
I understand that medical information I share with Clinic with a Heart will be kept confidential.
I was provided with a copy of Clinic with a Heart's notice of privacy practices for my review.
My signature below confirms that I have reviewed and agreed to consents.
*
Yes
No
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Witness
At any time, have you tested positive for Covid-19?
Yes
No
What was the date of your positive Covid-19 test result?
-
Month
-
Day
Year
Date
Demographics
Patient Name
*
First Name
Last Name
Appointment Reason:
Medical/Chiropractic/Mental Health
Dental
Please describe what you want to discuss with your medical provider?
*
Please describe what you want to discuss with your dental provider?
*
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Age
*
Parent or legal guardian name
First Name
Last Name
Gender
*
Female
Male
Other
Marital Status
*
Single
Married
Widowed
Divorced
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
-
Area Code
Phone Number
Phone Type
*
Cell
Landline
Work
Is it OK to text this phone?
*
No
Yes
Email Address
example@example.com
Which of the following best describe you (check all that apply):
*
American Indian/Alaskan Native
Asian
Black
Hispanic or Latino
Middle Eastern
Native Hawaiian
Pacific Islander
White
I prefer not to answer
Have you served in the United States Military?
*
No
Yes
I prefer not to answer
What language is the patient most comfortable speaking?
*
English
Spanish
I prefer not to answer
How well does the patient speak English?
*
Excellent
Good
Fair
Poor
Not at all
I prefer not to answer
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Does the patient have insurance?
*
None
Medicaid
Medicare
Insurance through work
Social and Emotional Health
How often does the patient see or talk to people that they care about and feel close to?
*
Less than once a week
1 or 2 times a week
3 to 5 times a week
More than 5 times a week
Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled.
*
Not at all
A little bit
Somewhat
Quite a bit
Very much
Does the patient feel safe?
*
Yes
No
If the patient had not come to Clinic with a Heart to get care, how likely is it that the patient would have gone to the emergency room to get care?
*
Extremely likely
Likely
Unlikely
Extremely Unlikely
Family and Home
Including yourself, how many people live in your household?
*
What is your housing situation today?
*
I have housing
I do not have housing -- I am staying with others
I do not have housing -- I am staying in a hotel
I do not have housing -- I am living in a shelter
I do not have housing -- I am living outside or in my car
Are you worried about losing housing?
*
No
Yes
What is the highest level of school you have finished?
Less than a high school diploma
High school diploma/GED
Some college
College degree
What is your current work situation?
Unemployed and seeking work
Unemployed and not seeking work (retired, disabled, etc)
Employed full-time
Employed part-time
What is your families combined yearly household income?
no income
Less than $12,000/year
$12,001 - $16,000/year
$16,001 - $24,000/year
More than $24,000/year
In the past year have you, or any family members you live with, been unable to get any of the following when it was really needed (check all that apply)?
Food
Clothing
Utilities
Child Care
Phone
Medicine or Healthcare
None
Has a lack of transportation kept you from doing what you need to do?
No
Yes
Have you been in jail or prison in the last 30 days?
No
Yes
How did you hear about Clinic with a Heart?
Back
Next
Health History
Reason for visit
Do you have any drug allergies?
*
No
Yes
What are you allergic to and what is your reaction?
Drug Name
What is your reaction
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Allergy 5
Allergy 6
Allergy 7
Allergy 8
Allergy 9
Allergy 10
Are you currently taking any medications (including over the counter medicine and vitamens)?
*
Yes
No
What medications do you currently take including over the counter and vitamins (if you do not take any medication write none in the first row)?
*
Medication Name
Dosage
How often do you take
Why do you take this medicine
Last dose (date and time)
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Eleven
Twelve
Thirteen
Fourtenn
Fifteen
Where do you usually go for your medical care?
*
Do you have a regular doctor?
*
No
Yes
Do you have a regular dentist?
No
Yes
Who is your regular doctor?
Who is your regular dentist?
Why did you come to Clinic with a Heart, rather than going to your regular doctor?
Are you currently in a treatment center/program?
No
Yes
Is your visit today due to a work related illness, injury or accident?
*
No
Yes
Who was your employer at the time of the injury?
Employer's Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What was your job title at the time you were injured?
On what date did the injury occur?
-
Month
-
Day
Year
Date
Approximately what time did the injury occur?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What type of work was being performed at the time of injury?
Describe the accident or injury?
Was the accident directly related to your work?
No
Yes
Was anyone else present during your accident?
No
Yes
Did you report your accident to your employer?
No
Yes
What recommendations did your employer make just after the accdient?
Have you been able to work since the injury?
No
Yes
Are your work activities restricted as a result of this injury?
No
Yes
Have you retained an attorney?
No
Yes
Is your visit today due to a motor vehicle accident?
*
No
Yes
Do you smoke?
*
No
Yes
How many packs a day?
How often do you drink?
*
Never
Sometimes
Daily
How often do you use street drugs?
*
Never
Sometimes
Daily
Excluding pregnancies, have you been to the Emergency room or hospitalized in the past 24 months?
Year
What was the illness or operation
Reason 1
Reason 2
Reason 3
Reason 4
Regarding your dental visit:
*
No
Yes
Are your teeth sensitive to cold/hot/sweets or pressure?
Do you have swelling?
Do you have throbbing pain?
Have you been prescribed antibiotics for your dental concern?
Have you been to the ER regarding your dental concern?
Have you ever had an unfavorable experience during a dental visit?
How long have you been experiencing your dental issue?
What have you done to relieve your dental pain?
Health History
Please review and let us know of any current health issues you may have?
Are you currently pregnant?
*
No
Yes
Don't Know
Are you using birth control?
*
Yes
No
Approximate date of last menstrual cycle?
*
Allergic/ Immunologic/ Hematologic/ Endocrine
*
No
Yes
Allergies/Hayfever
Anemia/Bruise easily
Cancer
Diabetes
Thyroid disease
Cardiovascular
*
No
Yes
Pace maker or an internal defibrillator
Chest pain
Heart disease
Heart Murmur
High blood pressure
High cholesterol
Stroke
Gastrointestinal
*
No
Yes
Abdominal pain
Bowel problems
Eating Disorder
Gall bladder trouble
Hepatitis
Jaundice
Ulcers
General/Constitutional
*
No
Yes
Fatigue
Loss of appetite
Recent weight loss
Recurrent infections
Skin rashes
Genitourinary
*
No
Yes
AIDS/ HIV
Kidney problems
Prostate disease
Sexually transmitted infections (STI)
Urination problems
Eyes/ Ears/ Nose/Mouth/ Throat
*
No
Yes
Blindness
Blurred vision
Eye pain
Glaucoma
Hearing loss
Macular degeneration
Neurologic/ Psychiatric
*
No
Yes
Depression or mental illness
Dizziness
Fainting
Headaches/ Migraines
Numbness/ Tingling sensations
Seizure disorder
Tremors/ Hands shaking
Orthopedic
*
No
Yes
Arthritis
Back pain
Bone Fracture
Muscle or joint pain
Osteoporosis
Respiratory
*
No
Yes
Asthma/ Wheezing
Bronchitis
Chronic cough > 3 weeks
Shortness of breath
Tuberculosis/ Exposure
Do you have any other health concerns not listed?
*
Name of person registering the patient (staff or volunteer)
First Name
Last Name
Submit
Patient Resource Sheets
Please put the resource sheets with dates next to them in the patients folder to be given to them at discharge.
Veteran's Resources (grey)
Healthcare Resources (bright pink)
Mental Health Resources (yellow)
Housing Resources (light purple)
Rent/Utilities (bright orange)
Employment assistance (red)
Food (bright green)
Clothing (bright blue)
Child care (white)
Phone (light pink)
Miscellaneous (light pink)
Well Woman Resources (grey)
Work Injury
Do you feel safe (if there is a date next to this, please discretely contact staff)
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm