Language
English (US)
Spanish (Latin America)
Specialty Clinic
| Pain Management | Orthopedic | Podiatry | Dermatology | Hypertension | | Physical Therapy |
Appointment Date
-
Month
-
Day
Year
Date
Consent and Privacy Notices
Consents and permissions to share information
*
Yes
No
I give the staff of Clinic with a Heart the permission to treat me or my minor child.
I understand that if I am prescribed medicine it will be from a limited list of available medications and will be for a maximum 60-day supply.
I understand that Clinic with a Heart does not prescribe narcotics or controlled substances.
I give permission for Clinic with a Heart to share my health information with referral agencies as needed.
I understand that medical information I share with Clinic with a Heart will be kept confidential.
Signature
*
Patient Name
*
First Name
Last Name
Patient Birthday
*
-
Month
-
Day
Year
Patient Gender
*
Female
Male
Other
Patient Phone Number
*
Must be a phone that we can contact the patient. Must be a United States contact number.
What type of phone is the phone number for?
*
Cell Phone
Landline
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Medical History
Medications and Allergies are included in the information below.
Have there been any changes to your health since your last visit to Clinic with a Heart?
*
Yes
No
Please explain the changes to your health
*
Does the patient have insurance?
*
Yes
No
Other
Does the patient feel physically and emotionally safe where they currently live?
*
Yes
No
Do you currently use any of the following nicotine or tobacco products?
*
Chewing Tobacco
Cigars
Cigarettes
Tobacco Pipes
Nicotine Replacement Gum or Patches
E-Cigarettes
Vaping Products
None of the above
How many times a day do you smoke or use any of the above selected products?
Less than 10 times a day
11-20 times a day
21-30 times a day
How often do you drink Alcohol in a week?
Never
1-2
3-4
5 or more times
How often do you use recreational/street drugs in a week?
Never
1-2
3-4
5 or more times
What drugs do you use?
Do you have any known allergies?
*
Yes
No
Please list any allergies below.
*
Do you take medication(s)? (Including vitamins, supplements, or over-the-counter medicines)
*
No
Yes
Other
What medicine do you currently take?
*
Med Name
Dosage
How often do you take?
Why do you take this medicine
Notes
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Med 9
Med 10
Med 11
Med 12
Med 13
Med 14
Med 15
Medications Comment:
Submit
Should be Empty: