New Patient Check-in Form

PATIENT INFORMATION FORM

DATE:

DATE OF BIRTH:

SS#

LAST NAME:

FIRST NAME:

Add new row

Or check this box if Homeless:

CELL PHONE:

OTHER PHONE:

EMAIL ADDRESS:

Would you like Portal access to view your chart? (Need email address for portal access)

Yes No

Do we have your permission to text information to you? (Need cell phone number to text)

Yes No

AGE:

GENDER:

RACE:

Arab

Asian

Black/African American

Native American

White Caucasian

Mixed Race

Other

ETHNICITY:

Hispanic/Latino or Non-Hispanic/non-Latin origin

MARITAL STATUS:

VETERAN:

Yes No

HEAD OF HOUSEHOLD:

Yes No

TOTAL # IN HOUSEHOLD:

ANNUAL HOUSEHOLD INCOME:

ANNUAL PERSONAL INCOME:

EMPLOYED/UNEMPLOYED:

EMPLOYER:

MEDICAL INSURANCE STATUS:

(Your insurance will NOT be charged; information needed for referrals only)

No Health Insurance Yes

Medicaid

Medicare

CareNet

Other

If other, specify:

DO YOU HAVE A HEALTH CARE PROVIDER:

No Yes

their name is:

PHARMACY OF CHOICE:

HOSPITAL:

EMERGENCY CONTACT NAME:

Their phone number:

Their relationship to you:

WHAT BRINGS YOU TO THE CLINIC TODAY?

HOW DID YOU HEAR ABOUT THE CLINIC?

HOW CAN WE PRAY FOR YOU TODAY?

SOCIAL DETERMINANTS OF HEALTH:

1. In the past year, have your or any family members you live with been unable to get food?

Yes No

2. Are you worried about losing your housing?

Yes No

3. Do you feel financially strained to make your ends meet?

Yes No

4. Has lack of transportation kept you from medical appointments, meetings, work, or getting things needed for daily living?

Yes No

If you have answered yes to any of these questions, please ask our receptionist for an Assistance Referral Form or speak with one of our nurses.

ALLERGIES:

To medication:

To foods:

Other allergies:

MEDICAL HISTORY

Check all that apply:

CARDIAC

Heart Disease

Heart Attack/Stroke

Heart Valve Problems

High Blood Pressure

High Cholesterol

Heart Arrythmias (A-fib)

OTHER

If other, specify:

ENDOCRINE

Diabetes type 1

Diabetes type 2

Thyroid

PCOS

OTHER

If other, specify:

SEXUALLY TRANSMITTE DISEASES

HIV/AIDS

Chlamydia

Gonorrhea

Trichomoniasis

Syphilis

Herpes

OTHER CONDITIONS

ARTHRITIS

MIGRAINES

HEARTBURN (GERD)

Ulcers

Urinary Problems

Vision Problems

Other

If other, specify:

BEHAVIORAL/MENTAL HEALTH

Anxiety

Bipolar Disease

Depression

Post Traumatic Stress

ADHD

Other

If other, specify:

RESPIRATORY

Chronic Cough

Shortness of Breath

Bronchitis

Asthma

Emphysema (COPD)

Other

If other, specify:

WOMEN’S HEALTH:

Last menstrual Period

Current Birth Control

Number of live births

Have you started menopause?

Date of last PAP

Date of last Mammogram

Number of miscarriages/abortions

Any menstrual problems?

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