CWH Patient Admission Packet (filled out by patient)

Clinic Date

Month Day Year
Date
Consents

Consent *

Yes

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 including the Consent and Affirmation form Covid-19). *

Yes No
Patient Signature *
Date *

Month Day Year
Date
Witness
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 *
Marital Status *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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 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 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
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?

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Consents

Demographics

Social and Emotional Health

Family and Home

Health History

Health History

Patient Resource Sheets