School Physical Pre-Admission Packet

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 (see below).

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
School Physical Needs:

Exam Vision Screening Dental Screening (Early childhood, K-4th Grades, 7th Grade, 10th grade)
Does the student have any allergies to medicine? *

Yes No
What is the allergic reaction?
Student's Date of Birth *

Month Day Year
Date
Student's Age *
Parent or legal guardian name

First Name Last Name
Student's Gender *
Student's 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 the student? Check all that apply. *

American Indian/Alaskan Native Asian Black Hispanic or Latino Native Hawaiian Pacific Islander White 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 I prefer not to answer.
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 I prefer not to answer.
Does the patient feel safe? *

Yes No I prefer not to answer.
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 I prefer not to answer
Family and Home

Please complete this information on behalf of the household (not just the student)
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. I prefer not to answer.
Are you worried about losing housing? *

No Yes I prefer not to answer.
What is the highest level of school the parent/guardian has finished? *

Less than a high school diploma High school diploma/GED Some college College degree I prefer not to answer.
What is the parent or guardian's current work situation? *

Unemployed and seeking work Unemployed and not seeking work (retired, disabled, etc) Employed full-time Employed part-time I prefer not to answer
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 I prefer not to answer.
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 the parent or guardian from doing what they need to do? *

No Yes
How did you hear about Clinic with a Heart?

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?
Name of person registering the patient (staff or volunteer)

First Name Last Name

Type a question

	Medication Name	Dosage	How often do you take	Why do you take this medicine	Last dose (date and time)
One
Two
Three
Four
Five

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:

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Consents

Demographics

Social and Emotional Health

Family and Home

Patient Resource Sheets