NEW PATIENT INFORMATION (First page) (ENGLISH)

PATIENT INFORMATION

LIVINGSTONE COMMUNITY HEALTH CLINIC
TODAY'S DATE*

MonthDayYear
REFERRED BY
LAST NAME*
FIRST NAME*
MIDDLE NAME
Gender*

MaleFemale
BIRTHDATE*

MonthDayYear
AGE
EMAIL*
example@example.com
PHONE
WORK PHONE
CELL PHONE*
Ok to Text Message*

YesNo
ADDRESS*
CITY*
STATE*
ZIP*
EMPLOYER
EMPLOYER ADDRESS
NAME OF SPOUSE (OR PARENT/GUARDIAN)
SS#/SIN OF PATIENT (OR SPOUSE/GUARDIAN)
SPOUSE OR GUARDIAN ADDRESS
SPOUSE OR GUARDIAN PHONE
EMERGENCY CONTACT NAME*
RELATION TO PATIENT*
EMERGENCY CONTACT PHONE*
EMERGENCY CONTACT ADDRESS
SOURCE OF INCOME

EARNEDRETIREMENTGENERAL PUBLIC ASSISTANCEDISABILITYOTHERNone
If other, explain
RACE*

AMERICAN INDIAN/ALASKAN NATIVEASIAN/PACIFIC ISLANDERAFRICAN AMERICANWHITE OR HISPANIC/LATINOMORE THAN ONE RACEOTHER/UNKNOWN
GENDER IDENTITY*

MALEFEMALETRANSGENDER MANTRANSGENDER WOMANCHOOSE NOT TO DISCLOSEOTHER/UNKNOWN
SEXUAL ORIENTATION*

LESBIAN OR GAYHETEROSEXUAL(OR STRAIGHT)BISEXUALSOMETHING ELSEDON'T KNOWCHOOSE NOT TO DISCLOSEUnknown
ETHNICITY*

HISPANIC/LATINONON-HISPANIC/LATINOUNKNOWN
MARITAL STATUS*

MARRIEDWIDOWEDSINGLE SEPARATEDSINGLE HEAD OF HOUSEHOLDDIVORCED
NUMBER OF FAMILY MEMBERS
FAMILY MONTHLY INCOME
FAMILY ANNUAL INCOME*
DO YOU HAVE INSURANCE?*

YESNO
INSURANCE NAME
TOBACCO USED BY PATIENT*

YESNO
PATIENT EXPOSED TOBACCO?*

YESNO
I UNDERSTAND THAT I AM THE RESPONSIBLE PARTY AND FINANCIALLY RESPONSIBLE FOR ALL CHARGES (DEDUCTIBLES, CO-INSURANCES, ETC FOR ALL SERVICES TO ME, INCLUDING THE BALANCE REMAINING AFTER PAYMENT OF POSSIBLE INSURANCE BENEFITS.

ASSIGNMENT OF BENEFITS

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO MYSELF OR THE NAMES PROVIDED FOR PROFESSIONAL SERVICES RENDERED.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
I HEREBY AGREE, CONSENT AND AUTHORIZE LIVINGSTONE COMMUNITY HEALTH CLINIC ANY AND ALL PHYSICIANS, PHYSICIAN'S ASSISTANTS, NURSE PRACTITIONERS, PARAPROFESSIONALS INCLUDING MEDICAL STUDENTS, RESIDENTS, INTERNS AND/OR ITS EMPLOYEES TO ORDER OR CONDUCT ANY AND ALL MEDICAL/DENTAL/PSYCHOLOGICAL/DIAGNOSTIC/RADIOLOGICAL STUDIES, TREATMENT, DISPENSE MEDICATION OR ANY AND ALL OTHER TREATMENT, WHICH THEY CONSIDER NECESSARY AND/OR ADVISABLE FOR MY PHYSICAL, DENTAL, AND MENTAL CONDITION.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Livingstone Community Health Clinic- Pediatrics Patients Intake
Birth Weight
Length(cm/in)
Pregnancy Length

LengthPretermUnsure
Delivery Method

Vaginal DeliveryC-sectionBreechTwin
Complications or problems in Newborn Period:

Breathing problemJaundiceFeeding probleminfectionNICU stayNoneOther
Complications or Problems During Pregnancy
Medications Taken During Pregnancy
Medical History
Type a question

History of bone fractureProblems with hearing or earsAsthmaFrequent ear infectionsKidney or bladder infectionEczemaPneumoniaAnemia or bleeding problemThyroid problemHistory of family violenceHistory of serious injuries/traumaAutismCancer HIV or other STD’sHistory of drug abuseNoneHeart murmur / Heart problemDevelopmental problemCongenital or genetic problemADHD / depression / anxietyProblems with vision or eyesSeizure / other neurological problemChicken poxOther
Surgical History
Year
Surgery type
Hospitalization
Year
Reaon
Hospital
Tuberculosis Risk Assessment

Please check one of the boxes below
Check one

Birth, travel, or residence in a country with an elevated TB rate for at last 1 monthImmunosuppression, current or plannedclose contact to someone with infectious TB disease during lifetimeNone; no TB testing is indicated at this time
Guardian's name

First NameLast Name
Guardian's Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

Livingstone Community Health Clinic- Pediatrics Patients Intake

Medical History