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School Physical - Intake Paperwork
When you are done, hit the submit button. When you see the green check mark the form is complete. We will be notified when the green check mark appears.
Clinic Date
-
Month
-
Day
Year
What day is the appointment?
Parent/Guardian Consents
Parent/Guardian 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).
Will the Parent or Legal Guardian be present for the student's appointment? (Please know, all students must have a Parent or Legal Guardian with them for their appointment. No Minor Child will be seen without a Parent or Legal Guardian)
*
Yes, I am the parent
Yes, I am the Legal Guardian
No, no Parent or Legal Guardian will be present
Authorized Consent and Appointment of Agent
I authorize the nurse and/or physicians employed or contracted by of Lincoln-Lancaster County Health Department (LLCHD) to screen for, and administer appropriate immunizations to my minor child,
Student's Name (Minor Child),
*
First Name
Last Name
in my absence, and in accordance with the LLCHD's schedules and policies, which I have authorized in writing. Further, I hereby appoint (an adult 19 years or over)
*
First Name
Last Name
as my agent and representative for the purpose of authorizing and consenting to hospital and/or medical care of the above-named Minor Child for any reaction to vaccines, illness, or injury while such person is in the care of the LLCHD when I am not immediately available to otherwise give such consent.
*
First Name
Last Name
Authorized Agent's Phone:
Please enter a valid phone number.
Known Allergies of Minor Child:
Minor Child's Primary Physician:
Physician's Phone:
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
Parent or Legal Guardian Name
First Name
Last Name
Parent or Legal Guardian Signature
Clear
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
please fill in the information for the patient, not the guardian.
Student Full Name (please provide the student's full legal name)
*
First Name
Last Name
What is the student's gender?
*
Male
Female
Other
Student's Date of Birth
*
-
Month
-
Day
Year
Date
School Physical Needs:
*
Exam
Vision Screening
Dental Screening (Early childhood, K-4th Grades, 7th Grade, 10th grade)
What medications/supplements/vitamins does the student take?
Medication Name
Dosage
How often
Why
Last dose
One
Two
Three
Four
Five
Are there other medications/supplements/vitamins not listed above that the student takes?
Does the student have any allergies to medicine?
*
Yes
No
What is the allergic reaction?
Demographics
please fill in the information for the patient, not the guardian.
Parent or Legal Guardian Name
First Name
Last Name
Student's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What County does the patient live in?
*
Lancaster
Saline
Douglas
Other
Primary Phone
*
Phone Type
*
Please Select
Cell
Landline
Work
Is it OK to text this phone?
No
Yes
Email Address
example@example.com
What School District is the patient going to attend?
*
Lincoln Public Schools
Crete Public Schools
Omaha Public Schools
Seward Public Schools
Other
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
Other
What language is the patient most comfortable speaking?
*
English
Spanish
I prefer not to answer
Other
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
*
Does the patient have insurance?
*
None
Medicaid
Medicare
Insurance through work
Other
Social and Emotional Health
Please answer the student's answers
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
Other
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?
Does the patient have a regular doctor?
*
No
Yes
Do the patient have a regular dentist?
No
Yes
Who is the patient's regular doctor?
Who is the patient's regular dentist?
Why did the patient 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
Submit
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)
Name of Witness RN/Volunteer
First Name
Last Name
Should be Empty: