Rise N Shine PHC Client Intake
(706) 450-0999
Date
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Month
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Day
Year
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Patient Name
*
First Name
Middle Name
Last Name
AGE
*
Preferred Name or Nickname
Patient Gender
*
Please Select
Male
Female
Spouse/ Auth Care Rep
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
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American Samoa
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Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Croatia
Cuba
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Equatorial Guinea
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Estonia
Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
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Netherlands
Netherlands Antilles
New Caledonia
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Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
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Norway
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Papua New Guinea
Paraguay
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Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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eSwatini
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SSN
*
### - ## - ####
Patient Birth Date
*
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Year
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Patient E-Mail
*
Work Status
Employed
Unemployed
Retired
Disabled fom work
Employer
Occupation
Marital Status:
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Insurance - Primary
Subscriber Name
Subscriber Birth Date
*
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December
Month
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Relationship to Patient
Subscriber SSN/ID
Group Number
Behavioral Health Insurance Carrier (may be different than medical)
Subscriber Employer
PCP Name
Medical History
PCP Phone Number
PCP Fax #
Do you use tobacco in any form?
Yes
No
If yes, please list type , amount and frequency of use
Do you use Alcohol in any form?
Yes
No
If yes, please list type, amount and frequency of use
Are you taking any medication? If yes, please list medication and doage per day
Please check all problems you are experiencing
Yes
No
Abnormal Bleeding
Alcohol Abuse
Allergies
Alzheimers
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
COPD
Dementia
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Multiple Sclerosis
Pace Maker
Paralysis(Quad, Para)
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Allergies
Other
Brief Description of the person that you are requesting care for and services required.
Assignment and Release
All payments are made payable to Rise N Shine Personal Home Care LLC. Accepting cash, money orders, and cashier checks. There is a $30.00 fee on all bounced checks.
Dental History
How many times do you:
floss/week
brush/day
Please answer the following
Yes
No
Are your teeth sensitive to heat, cold or anything else?
Do you gag easily?
Dentures
Is there any specific service and/or concern you would like to inquire about?
Submit
Should be Empty: