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- Clinic Date
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- Date of Birth*
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- Appointment Reason:*
- Have you been to Clinic With A Heart in the last 6 months?
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- Do you have any drug allergies?*
- What are you allergic to and what is your reaction?
- 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.)*
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- Consent*
- My signature below confirms that I have reviewed and agreed to consent.*
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- 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.
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- What county do you live in?*
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Format: (000) 000-0000.
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- Is it OK to text this phone?*
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- Which of the following best describe you? (check all that apply):*
- What language is the patient most comfortable speaking?*
- How well does the patient speak English?*
- Have you served in the United States Military?
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Format: (000) 000-0000.
- Does the patient have insurance?*
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- 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?*
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- 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
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- Do you have a regular doctor?*
- Do you have a regular dentist?
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- Are you currently in a treatment center/program?
- Is your visit today due to a work-related illness, injury, or accident?*
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- On what date did the injury occur?
- At approximately what time did the injury occur?
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- Was the accident directly related to your work?
- Was anyone else present during your accident?
- Did you report your accident to your employer?
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- 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?
- Regarding your dental visit:*
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- Are you currently pregnant?*
- Are you using birth control?*
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- Allergic/ Immunologic/ Hematologic/ Endocrine*
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- Cardiovascular*
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- Gastrointestinal*
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- General/Constitutional*
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- Genitourinary*
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- Eyes, Ears, Nose, Mouth, Throat*
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- Neurologic/ Psychiatric*
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- Orthopedic*
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- Respiratory*
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