School Physical Pre-Admission Packet

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

MonthDayYear
What day is the appointment?
Parent/Guardian Consents

Parent/Guardian 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 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)
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 NameLast 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 NameLast 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 NameLast Name
Authorized Agent's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Known Allergies of Minor Child:
Minor Child's Primary Physician:
Physician's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Parent or Legal Guardian Name

First NameLast Name
Parent or Legal Guardian Signature
Address

Street Address

Street Address Line 2

CityState / 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 NameLast Name
What is the student's gender?

Other
Student's Date of Birth

MonthDayYear
Date
School Physical Needs:

What medications/supplements/vitamins does the student take?

Rows	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?
What is the allergic reaction?
Demographics

please fill in the information for the patient, not the guardian.
Parent or Legal Guardian Name

First NameLast Name
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County does the patient live in?

Other
Primary Phone
Format: (000) 000-0000.
Phone Type
Is it OK to text this phone?
Email Address
example@example.com
What School District is the patient going to attend?

Other
Which of the following best describe the student? Check all that apply.

Other
What language is the patient most comfortable speaking?

Other
How well does the patient speak English?
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Does the patient have insurance?

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?
Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. Does this describe the patient?
Does the patient feel physically and emotionally safe where they currently live?
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?
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?
Are you worried about losing housing?
What is the highest level of school the parent/guardian has finished?
What is the parent or guardian's current work situation?
What is your family's combined yearly household income?
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.

Other
Has a lack of transportation kept the parent or guardian from doing what they need to do?
How did you hear about Clinic with a Heart?
Does the patient have a regular doctor?
Does the patient have a regular dentist?
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 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)
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 NameLast Name
Should be Empty:

School Physical - Intake Paperwork

Parent/Guardian Consents

Authorized Consent and Appointment of Agent

Medical History

Demographics

Social and Emotional Health

Family and Home