• PATIENT INTAKE FORM

    PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976
  • Date of Birth *
     - -
  • Gender at Birth*
  • Today's Date
     - -
  • Since you are under age 18, are your parents aware of your visit?*
  • Is your physical address different than your mailing address?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is a translator needed?*
  • Marital Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How do you want to be contacted about your appointments? (select all that apply)*
  • How do you want to be contacted about your results? (select all that apply)*
  • How do you want to be contacted for your bill? (select all that apply)*
  • I agree to allow access to my prescription history*
  • Are you agricultural worker*
  • Are you student*
  • If yes, what describes your status:*
  • Are you homeless*
  • Employment*

  • ONLINE PATIENT PORTAL AUTHORIZATION

    We encourage the use of Online Patient Portal where you can access your chart to see your information such as lab and x-ray results, and current medications & communicate with your provider via a secure email. Often, this secure email is the fastest way to communicate with your provider. 

  • Do you wish to sign up? (you can view your lab results online)*

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976
  • Do you have medical insurance?*

  • IF RESPONSIBLE PARTY IS OTHER THAN YOU:

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Date of Birth
     - -

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • We receive partial funding from Federal and State grants. Our continued services rely heavily on your payments and donations. You will never be denied services because of an inability to pay.

    To ensure that everyone can afford our services, our charges are based on a sliding fee scale. This information is required to determine your fees and as a condition of the grants we receive to bring affordable services to our community. We will not share your income information with anyone else.

    We require the below information from all clients whether you have insurance or not. We encourage you to use your insurance whenever it is available, and you will never pay more by using your insurance than you would without it.

     

    All our visits are confidential, however, when we bill insurance, some insurance carriers send information about your care to the policy holder.

  • Do you want fees reduced on a sliding fee scale?*
  • All our visits are confidential, however, when we bill insurance, some insurance carriers send information about your care to the policy holder.*
  • Would you like to designate a family member or other individual with whom the provider may discuss your medical condition?*

  • May list up to three people
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Have you served in the active military, naval, or air service, which includes full-time service in the Air Force, Army, Coast Guard, Marines, Navy, or as a commissioned officer of the Public Health Service or National Oceanic and Atmospheric

    Administration or served in the National Guard or Reserves on active-duty status?

  • *

  • ACKNOWLEGEMENTS: All 3 of these documents will be e-mailed to you have completing intake paperwork

  • Acknowledgement of Cosumer Bill of Rights: I acknowledge receipt of the Consumer Bill of Rights

  • Acknowledgement of Cosumer Privacy Practices: I acknoledge receipt of the Privacy Practices

  • Acknowledgement of Cosumer Payment Policy: I acknoledge receipt of the Payment Policy and agree to abide by it

  • CONSENT & ASSIGNMENT

    I consent to integrated medical, mental health, behavioral health and dental services for me or the individual for whom I am the personal representative and hereby accept responsibility to pay for such services. I know that it is my choice to have services and can change my mind about receiving services at/One Health. In the event I receive family planning services, I understand that such family planning services are provided on a voluntary basis and are not a pre-requisite to eligibility for, or receipt of, any other services or programs of Hill County Family Planning/One Health. Individuals 18 years of age and younger may consent to the receipt of family planning services without parental notification or consent. All information as to personal facts and circumstances obtained by/One Health staff will be held strictly confidential and will not be disclosed without your written consent, except as necessary to provide services to you or as required by law, with appropriate safeguards for confidentiality. I understand that I have the right to receive free language interpreter services. I understand that I must tell the staff if these services will be helpful to my understanding of the written or spoken information given during my healthcare visits. Hill County Family Planning/One Health as my lawful agent and assign to hereby designate Hill County Family Planning/One Health any benefits for medical, dental, behavioral health, mental health, Hill County Family Planning/One Health which I may be entitled to. or any other services I receive from You may ask for a copy of this form or any form that you sign.

    I further consent to receiving the services described above via telehealth if it is necessary or appropriate for the current situation. Telehealth uses electronic communications, such as real time audio, video, and data communications, so health care providers at different locations can share a patient's health information to diagnose, consult, and/or treat the patient. To protect the privacy and security of patient health information, all electronic communications used for telehealth comply with network and software security protocols. As with any health care service, there are benefits and possible risks with the use of telehealth. The benefits of using telehealth include improved access to health care and the expertise of providers and/or specialists who are not physically located in the geographic area. Possible risks of using telehealth include possible delay in diagnosis or treatment due to technical difficulties with equipment; information being sent is not sufficient to allow for a complete medical exam by the offsite provider; information may be lost when being sent due to technical failures; and despite security protocols being in place, the privacy of patient health information may be compromised when sent electronically. If I participate in a telehealth session where I am located outside of the clinic, I understand that there is potential for other people to overhear sessions if I am not in a private place. In such cases, I understand that it is my obligation to take reasonable steps to ensure my privacy. I have the right to withhold or withdraw my consent to the use of telehealth without affecting my right to future care or treatment. By signing in the space below,

    I consent to receive services via telehealth.

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Medical History

  • Date of Birth
     - -
  • Today's Date
     - -
  • Have you been in the ER or hospitalized in the last year?*
  • Have you ever had any surgeries?*
  • Have you ever had cancer?*
  • Have you ever had hearing problems?*
  • Have you had a mammogram and/or breast ultarsound?*
  • Have you had acne or other skin problems?*
  • Do you know about your family medical history?*

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Family History

  • Have your grandparents, parents, brothers or sisters ever had any of the following?

  • Blood clots in arms/legs/chest?*
  • Bleeding problems?*
  • High Blood Pressure*
  • High cholesterol/triglycerides*
  • Breast/ovarian/uterine/colon cancer*
  • Heart Attack*
  • Stroke*
  • Diabetes*
  • Birth defect/genetic disorders*
  • Mental health disorders*
  • Alcohol/Drug Abuse*
  • Physical or Sexual abuse*

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Personal Medical History

  • Rows
  • Do you smoke or use any form of tobacco?*
  • Do you drink alcohol?*
  • Do you ever feel you should cut down on your drinking?*
  • Have you used marijuana in the past year?*
  • In the past year, have you used an illegal drug or a prescription drug for non-medical reasons?*
  • Have you ever been hit, slapped, kicked, shaken or hurt by anyone?*
  • Is there anyone who makes you feel unsafe now?*
  • Have you ever been forced to have sex?*
  • Rows

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Sexual History

  • Have you EVER had oral, anal or vaginal sex?*
  • Rows
  • Have you or your sexual partner(s) ever used needles for drugs (to shoot drugs)?*
  • Have you or your sexual partner(s) ever exchanged sex for drugs or money?*
  • Do you use condoms?*
  • Does your partner have other partners?*
  • Have you had a HIV test?*
  • Was the HIV test positive?*
  • Are any of your partners living with HIV?*
  • Do you have (select all that apply):*
  • Are your sex partners (select all that apply):*
  • Have any of your male partners had sex with other men?*

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Male / Assigned male at birth / MTF

  • Your Urological History
  • Do you have abnormal discharge from your penis now?
  • Do you have now or in the past a lesion, sore or lump on your penis?
  • Have you ever had pain during sex?*
  • Have you ever had gender affirming surgery?*

  • Your Reproductive History
  • Do you have any children?*
  • Do you plan to have children?*
  • When?*
  • What form of birth control are you using (select all that apply)?*

  • PATIENT INTAKE FORM

    Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976

  • Female / Assigned female at birth / FTM

  • Your Menstural History
  • Date of the FIRST DAY of your last menstrual period
     - -
  • Was your last menstrual period normal?
  • Do you have a period every month?
  • How is the flow?
  • Do you bleed between periods?
  • Do you have cramps with your periods?
  • Do you take medications for cramps?
  • What type of medications are you taking?

  • Your Pregnancy History
  • Do you plan to have children?
  • When?
  • Are you breastfeeding now?*
  • Have you had a baby that weighed less than 5 1/2 pounds?*
  • Have you had a baby that weighed more than 9 pounds?*
  • During any pregnancy did you have high blood pressure, diabetes or a baby with birth defects?*

  • Your Gynecological History
  • Rows
  • Have you had an abnormal pap test?*
  • Was a coloscopy done?*
  • Did you get treatment for abnormal pap?*
  • Have you had a follow-up pap since then?*
  • Have you had gender affirming surgery?*

  • Your Birth Control History
  • Are you using a method of birth control now?*
  • Have you used a birth control method that you have problems with?*
  • In the last 5 days or since your last period, have you had sex without birth control? (condoms are birth control)?*

  • Click "submit" to finalize your paperwork

    We look forward to seeing you.
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