CWH Patient Admission Packet

Clinic Date

What day is your appointment scheduled?

Patient Primary Name

First NameLast Name

Date of Birth

Date

Gender

Appointment Reason:

Have you been to Clinic With A Heart in the last 6 months?

Please describe what you want to discuss with your medical provider?

Please describe what you want to discuss with your dental provider?

Do you have any drug allergies?

What are you allergic to and what is your reaction?

Rows	Drug Name	What is your reaction
Allergy 1
Allergy 2
Allergy 3

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

What medications do you currently take, including over the counter and vitamins? (If you do not take any medications, write "none" in the first row.)

Rows	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

Are you taking any other medications; including over-the-counter-meds, vitamins, supplements, etc?

Medication Comments

Consent

Rows	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 up to 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 60-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 consent.

My typed signature confirms that I have reviewed and agree to the consents.

First NameLast Name

Patient Signature

Date

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

Are you interested in a Colon Cancer Screening Test Kit? This would be free to you.

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.

If the patient is 18 or younger, who is the parent or legal guardian?

First NameLast Name

What is the patient's marital status?

Please fill out for the patient if the patient is a minor.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What county do you live in?

Other

Primary Phone

Format: (000) 000-0000.

Phone Type

Is it OK to text this phone?

Email Address

example@example.com

Which of the following best describe you? (check all that apply):

What language is the patient most comfortable speaking?

Other

How well does the patient speak English?

Have you served in the United States Military?

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Does the patient have insurance?

How often does the patient see or talk to people that they care about and feel close to?

Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. Does this describe the patient?

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?

Does the patient feel physically and emotionally safe where they currently live?

Including yourself, how many people live in your household?

What is your housing situation today?

Are you worried about losing housing?

What is the highest level of school you have finished?

What is your current work situation?

What is your family's combined yearly household income?

Have you been in jail or prison in the last 30 days?

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.)

If you are 45+, Are you interested in a Colon Cancer Screening Test kit

How did you hear about Clinic with a Heart?

Where do you usually go for your medical care?

Do you have a regular doctor?

Do you have a regular dentist?

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?

Is your visit today due to a work-related illness, injury, or accident?

Who was your employer at the time of the injury?

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What was your job title at the time you were injured?

On what date did the injury occur?

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?

Was anyone else present during your accident?

Did you report your accident to your employer?

What recommendations did your employer make just after the accident?

Have you been able to work since the injury?

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)?

Have you retained an attorney?

Is your visit today due to a motor vehicle accident?

Do you currently use any of the following nicotine or tobacco products? Please select one or more.

How often do you use any of the above chosen products

How often do you drink alcohol?

How often do you use street drugs including Marijuana?

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

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

Regarding your dental visit:

Rows	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?

How long have you been experiencing your dental issue?

What have you done to relieve your dental pain?

Are you currently pregnant?

Are you using birth control?

Approximate date of last menstrual cycle.

Allergic/ Immunologic/ Hematologic/ Endocrine

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

Notes:

Cardiovascular

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

Notes:

Gastrointestinal

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

Notes:

General/Constitutional

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

Notes:

Genitourinary

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

Notes:

Eyes, Ears, Nose, Mouth, Throat

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

Notes:

Neurologic/ Psychiatric

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

Notes:

Orthopedic

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

Notes:

Respiratory

Rows	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 NameLast Name

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)

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

Intake Paperwork

Allergies and Medications

Consents

Demographics

Social and Emotional Health

Family and Home

Health History

Health History