CWH Patient Admission Packet (filled out by patient)

Once you complete the form, please hit submit. When you see the green check mark and "Thank You," you will know the form has been submitted correctly. You may be asked to click on the "I am not a robot" button before submitting. We will get an email notifying us that the information is ready.
Clinic Date

Month Day Year
Date
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Patient Age *
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? *
Allergies and Medications
Do you have any drug allergies? *

No Yes

Are you currently taking any medications, including over the counter medicine and vitamins? *

Yes No

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 understand I may review Clinic with a Heart's notice of privacy practices and will be provided a copy if requested.

My signature below confirms that I have reviewed and agreed to consents. *

Yes No
Patient Signature *
Date *

Month Day Year
Date
Witness
Would you like a referral to go get lab work done for a prostate screening test? This would be free to you.

Yes No
At any time, have you tested positive for COVID-19?

Yes No
Heading
What was the date of your positive COVID-19 test result?

Month Day Year
Date
We are able to provide free healthcare because of generous donors. Would you be willing to share how Clinic with a Heart has helped you? If so, we would feature you in our monthly newsletters and our social media platforms.

Yes No
Demographics
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 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 Have applied for Medicaid Medicare Have applied for Medicare Insurance through work
Social and Emotional Health

We ask these questions to see if there are other resource recommendations we can make for you while you are at the clinic.
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. Does this describe the patient?

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 family's 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 Transportation None
Have you been in jail or prison in the last 30 days?

No Yes
Would you like information about how to get a COVID-19 vaccine?

Yes No
How did you hear about Clinic with a Heart?
Health History
Reason for visit
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
At 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 accident?
Have you been able to work since the injury?

No Yes
Are your work activities restricted as a result of this injury (if so, we ask additional questions so you have a good record of the incident in case you should need it)?

No Yes
Have you retained an attorney?

No Yes
Is your visit today due to a motor vehicle accident? *

No Yes
Do you smoke cigarettes/e-cigarettes? *

No Yes
How many packs a day?
How often do you drink alcohol? *

Never Sometimes Daily
How often do you use street drugs including Marijuana? *

Never Sometimes Daily

Excluding pregnancies, have you been to the emergency room or been hospitalized in the past 24 months?

	Year	What was the illness or operation
Reason 1
Reason 2
Reason 3
Reason 4

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
Are you using birth control? *

Yes No
Approximate date of last menstrual cycle. *
Health History

In the past have you had any of the following?

Allergic/ Immunologic/ Hematologic/ Endocrine *

	No	Yes
Allergies/Hayfever
Anemia/Bruise easily
Cancer
Diabetes
Thyroid disease

Notes:

Cardiovascular *

	No	Yes
Pacemaker or an internal defibrillator
Chest pain
Heart disease
Heart murmur
High blood pressure
High cholesterol
Stroke

Notes:

Gastrointestinal *

	No	Yes
Abdominal pain
Bowel problems
Eating disorder
Gall bladder trouble
Hepatitis
Jaundice
Ulcers

Notes:

General/Constitutional *

	No	Yes
Fatigue
Loss of appetite
Recent weight loss
Recurrent infections
Skin rashes

Notes:

Genitourinary *

	No	Yes
AIDS/HIV
Kidney problems
Prostate disease
Sexually transmitted infections (STI)
Urination problems

Notes:

Eyes, Ears, Nose, Mouth, Throat *

	No	Yes
Blindness
Blurred vision
Eye pain
Glaucoma
Hearing loss
Macular degeneration

Notes:

Neurologic/ Psychiatric *

	No	Yes
Depression or mental illness
Dizziness
Fainting
Headaches/Migraines
Numbness/Tingling sensations
Seizure disorder
Tremors/Hands shaking

Notes:

Orthopedic *

	No	Yes
Arthritis
Back pain
Bone fracture
Muscle or joint pain
Osteoporosis

Notes:

Respiratory *

	No	Yes
Asthma/Wheezing
Bronchitis
Chronic cough > 3 weeks
Shortness of breath
Tuberculosis/Exposure

Notes:
Do you have any other health concerns not listed? *
Name of person registering the patient (staff or volunteer)

First Name Last Name

Patient Resource Sheets

Please put the resource sheets with dates next to them in the patient's 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)
COVID-19 vaccine Information
Miscellaneous (light pink)
Phone (light pink)
Recently released from incarceration
Well Woman Resources (grey)
Work Injury
Do you feel safe (if there is a date next to this, please discretely contact staff)
Prostate screening referral
Menstrual Supplies

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	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

	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

	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?

Allergies and Medications

Consents

Heading

Demographics

Social and Emotional Health

Family and Home

Health History

Health History

Patient Resource Sheets