CWH Patient Admission Packet (filled out by patient)

Clinic Date

Date

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.

Please sign once you have read and agreed to the consent to treat. *

Clear

Witness

Patient Signature

Date *

Date

Patient Name *

First Name Last Name

Appointment Reason:

Medical Dental Mental Health

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 *

Date

Patient Age *

Parent or legal guardian name

First Name Last Name

Gender

Marital Status

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Primary Phone

Area Code Phone Number

Phone Type

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 Native Hawaiian Pacific Islander White

Have you served in the United States Military?

No Yes

What language is the patient most comfortable speaking?

English Spanish

How well does the patient speak English?

Excellent Good Fair Poor Not at all

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

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 5 or more 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

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?

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

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 Country

What was your job title at the time you were injured?

On what date did the injury occur?

Date

Approximately what time did the injury occur?

: Hour Minutes 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 last 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?

Are you currently pregnant?

No Yes Don't Know

If you are using birth control, what kind?

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

If you will be talking to a dentist, please take a picture or upload a picture of your face (so they can see with there is swelling)

Browse Files

To the best of your abilities, please take a picture or upload a picture of the gum or tooth that is giving your problems.

Browse Files

Do you have any other health concerns not listed?

Name of person registering the patient (staff or volunteer)

First Name Last Name

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)

Do you feel safe (if there is a date next to this, please discretely contact staff)

Consents

Demographics

Social and Emotional Health

Family and Home

Health History

Health History

Patient Resource Sheets