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HIPAA
Compliance
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1
Are you a NEW patient to iHealth Clinic?
YES
NO
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2
Patient's Name
*
This field is required.
First Name
Last Name
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3
Patient's Birth Date (Month-Day-Year)
*
This field is required.
-
Month
Day
Year
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4
Acknowledgement and Consent Form
*
This field is required.
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5
Medical Service Agreement
*
This field is required.
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6
*
This field is required.
By signing below, I acknowledge and consent to the Patient Acknowledgment and Consent Form and the Medical Service Agreement on behalf of myself, or other person who I am the legal representative.
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7
Contact Information
Please note: we often use text for reminders.
Please enter your Phone Number ex. 4122035810 (ONLY NUMBERS)
Please enter your Street Address ex. 6008 Centre Avenue
Please enter your Zip Code ex. 15206
Please enter your email (OPTIONAL)
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8
Is the Patient taking any Prescribed Medication?
*
This field is required.
Yes if medication is prescribed and taken regularly
YES
NO
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9
Does the Patient have any Allergies?
*
This field is required.
Amoxicillin/Ampicillin/Penicillin
Ibuprofen/Naproxen/NSAIDs
IV Contrast Dye
Sulfa drugs
NO ALLERGIES to medications
Other
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10
Has the Patient ever been diagnosed with any of these Medical Issues?
*
This field is required.
Alcohol Dependence
Allergies
Anxiety
Asthma
Bipolar
Coronary Artery Disease
COPD (Emphysema)
Depression
Diabetes
Drug Dependence
High Blood Pressure (Hypertension)
High Cholesterol
Heart Failure
Kidney Disease
Liver Disease
Neurological Disease
Stroke
NO MEDICAL ISSUES
Other
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11
Does the Patient Smoke Cigarettes, Cigars or Vape in the last 6 months?
*
This field is required.
YES
NO
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12
How much does the Patient Smoke?
*
This field is required.
only VAPES
only uses CIGARS
a FEW Cigarettes per day
1/4 Pack per day
1/2 Pack per day
1 Pack per day
1.5 Packs per day
2 Packs per day
Over 2 Packs per day
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13
Has the Patient drank Alcohol in the last 6 months?
*
This field is required.
YES
NO
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14
How much Alcohol does the Patient Drink on average?
*
This field is required.
One Alcoholic Serving = One Bottle/Can or One Shot of Hard Liquor or One Glass of Wine
Less than One Serving per Week
Less than One Serving per Day
One Serving per Day
More than One Serving per Day
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15
Does the Patient ever drink more than 3 Servings of Alcohol (for Females) or 4 Servings of Alcohol (for Males) at one time?
*
This field is required.
YES
NO
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16
Has the Patient ever used Illicit or Street Drugs in the last 6 months?
*
This field is required.
(including Marijuana)
YES
NO
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17
What kind of Illicit or Street Drugs has the Patient used?
*
This field is required.
Cocaine or Crack
Ecstasy (MDMA)
Inhalants
Marijuana
Methamphetamine (Meth)
Opioids (Heroin, Pain Medication, Fentanyl)
Sedatives (Ativan, Xanax, Klonopin, Valium)
Other
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18
FAMILY: What Medical Problems does the Patient's MOTHER have (or did have)?
*
This field is required.
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/NO Issues
Other
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19
FAMILY: What Medical Problems does the Patient's FATHER have (or did have)?
*
This field is required.
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/No Issues
Other
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20
FAMILY: What Medical Problem does the Patient's SISTERS have (or did have)?
*
This field is required.
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/NO SISTERS
NO Issues
Other
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21
FAMILY: What Medical Problems does the Patient's BROTHERS have (or did have)?
*
This field is required.
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/NO BROTHERS
NO Issues
Other
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22
FAMILY: What Medical Problems does the Patient's DAUGHTERS have (or did have)?
*
This field is required.
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/NO DAUGHTERS
NO Issues
Other
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23
FAMILY: What Medical Problems does the Patient's SONS have (or did have)?
(select
Allergies
Asthma
Blood Pressure Problems
Breast Cancer
Cholesterol Problems
Colon Cancer
Diabetes
Heart Disease
Kidney Disease
Neurological Disease
Stroke
UNKNOWN/NO SONS
NO Issues
Other
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24
How did you hear about iHealth Clinic? (after this you're all done!)
Coworker
Family or Friend
Facebook
Google or other Search Engine
Newspaper
Radio
TV
Other
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25
When was the Patient Last at iHealth Clinic?
Within a Week
Over a Week ago
I am a NEW Patient - I have never been here before
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26
Name
*
This field is required.
First Name
Last Name
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27
Birth Date
-
Month
Day
Year
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28
Has your Legal Name, Phone Number, Address or Email changed since last being here?
YES
NO
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29
What are the changes?
Please enter Patient's NEW LEGAL NAME if changed
Please enter Patient's NEW PHONE NUMBER if changed (only use numbers)
Please enter Patient's NEW ADDRESS if changed
Please enter Patient's NEW EMAIL if changed
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30
Has the Patient's Medications, Medical History, Social History (tobacco, alcohol or drug use) or Family History (medical history of family) changed since last being seen here?
YES
NO
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31
Describe what Medication has changed:
Describe what in the Medical History has changed:
Describe what in the Social History has changed:
Describe what in the Family History has changed:
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