PATIENT REGISTRATION

Transcription

1 Patient Information: PATIENT REGISTRATION Date: Name: (First) (Middle) (Last) Address: Social Security Number: Home phone: ( ) Date of Birth: Marital Status: Sex: Race: (please circle one) American Indian, Asian, Black, White, Native Hawaiian, Other Pacific Islander Ethnicity: (please circle one) Hispanic or Latino, Not Hispanic or Latino Are you a veteran? Yes No Are you homeless? Yes No Medical Insurance: Yes No Please bring your insurance card to your visit. If you do not have medical insurance, would you like to get information about our reduced fee program? Yes No Emergency Contact Person: (Name) (Relationship to patient) (Address) (Phone) Person Responsible for Payment: (Complete only if patient is less than 18 years old) Name: Relationship to patient: Social Security Number: Date of Birth: Address: Home phone: Cell phone: I agree that the above information is correct and accurate to the best of my knowledge. I also understand that any charge(s) not covered by my insurance(s) will be my responsibility. Signature: Date:

2 PERMISSION TO SHARE PROTECTED HEALTH INFORMATION Patient s Full Name: (Last) (First) (Middle) Patient s Date of Birth: / / Telephone: Keystone Health shares one electronic record. Any person(s) you authorize will have access to your financial/medical/dental and behavioral health information. Name: Relationship to Patient: Name: Relationship to Patient: Name: Relationship to Patient: Keystone Health uses a reminder system and/or patient portal to communicate with our patients. Please complete the information below, so that we may keep in touch with you regarding your health. Cell Phone : ( you will receive a text message) (you will receive an ) By signing, I give permission to Keystone Health to share my protected health information to the individuals listed. This Permission remains in effect until revoked in writing. Signature of Patient or Authorized Representative (Patient s 14 years and older must sign if consenting for treatment on own behalf) Date Staff Initials 7/30/18 ksw

3 KEYSTONE HEALTH Ages 7 17 years ADOLESCENT HEALTH HISTORY QUESTIONNAIRE Patient Name:_ Date of Birth: PAST ILLNESSES Please circle any illnesses that you ve had Asthma Hay Fever Tuberculosis Kidney trouble Heart murmur High Cholesterol Rheumatic Fever Sickle Cell Seizures Hepatitis Hyperactivity (ADD) Hearing loss Urinary tract infection Chicken pox Mumps Pneumonia Other: FEMALES ONLY Age at 1 st menstrual period: Have you ever had sex? Yes/No If the answer is yes, please answer these questions: Number of times pregnant: Number of living children: Date of last pap smear: Birth control method: Do you consider yourself to be: Heterosexual (straight) Homosexual (lesbian/gay) bisexual MALES ONLY Have you ever had sex? Yes/No If the answer is yes, please answer these questions: Do you use condoms (rubbers)? Yes/No Number of living children: Do you consider yourself to be: Heterosexual (straight) Homosexual (lesbian/gay) bisexual MEDICINES/ALLERGIES Please list any medicines that you take & allergies that you have: Medicines currently taking: Allergies: HOSPITALIZATIONS/SURGERIES/INJURIES FAMILY HISTORY Mother s name: Date of Birth: Living at home? Yes/No Mother s health: Occupation: Father s name: Date of Birth: Living at home? Yes/No Father s health: Occupation: 1

4 KEYSTONE HEALTH Ages 7 17 years ADOLESCENT HEALTH HISTORY QUESTIONNAIRE Family History Continued: Brothers and sisters: NAMES BIRTH DATES HEALTH PROBLEMS Please circle any diseases that your grandparents, parents, aunts, uncles, brothers or sisters have or have had: Asthma Hay Fever Stroke Kidney trouble Depression High Cholesterol Diabetes Seizures Heart attack Other: Polyps High blood pressure Alcoholism Cancer PERSONAL HISTORY Check Yes No Do you have any special interests/hobbies? Please list: Do you exercise at least 3 times a week? Do you limit sweets, fats and junk food in your diet? Do you always wear your seat belt? Do you wear a helmet when you ride a bicycle or motorcycle? Do you limit sun exposure or use sunscreens (#15 or higher) when tanning? Do you have any trouble tanning? Do you have any trouble reading? Have you ever been physically or sexually abused? Have you ever been verbally abused? Do you smoke cigarettes? Packs per day: Years: Do you chew tobacco? Do you smoke pot? Have you ever taken steroids? Do you ever use alcohol or drugs to feel better? Do your friends get drunk or high at parties? Do you get drunk or high at parties? Have you been drunk more than 10 times? Have your grades gone down recently? Have you ever been arrested? Below are some common concerns of teenagers. Please check yes or no to let us know if you have any of these concerns: YES NO Feeling bummed out, down or depressed: Trouble sleeping: Tired during the day: Pain with menstrual periods: Dizzy spells: Frequent headaches: Stomach pains: Worried about school: Worried about sex:

5 YES NO Worried about my height: Worried about my weight: Worried about my parents relationship: Other concerns: The rest of these questions are for you to see if you might be at risk to get AIDS. You do not have to write down your answers, but if any answers are yes, you could be at risk for AIDS and you should talk to your practitioner about it. YES NO Have you h ad more than one sexual partner in the last year? Has your partner had sex with anyone other than you, since you have been partners? Have you or your sexual partners ever used IV drugs? Have any of your sexual partners had AIDS or a positive HIV test? Have you ever had a venereal disease (VD)? Did you have a blood transfusion between 1979 and 1985? Have you had unprotected sex? FOR MALES: Have you ever had sexual contact with a male? FOR FEMALES: Have any of your sexual partners been bisexual makes, or have they had sex with other males? CLIENTS NAME: DATE COMPLETED: DO NOT WRITE BELOW THIS LINE FOR OFFICE USE ONLY! Family History (There are two methods of recording the family history. The diagrammatic format is more helpful than the narrative in tracing genetic disorders. The negative family information follows either format.) Train accident Stroke, varicose veins, headaches High Blood Heart Attack Pressure Infancy Migraine headaches Indicates patient Deceased male Deceased female Living male Living female Outline: Father died, 43, train accident Mother died, 67, stroke, had varicose veins, headaches One brother, 61, has high blood pressure, otherwise well One brother, 58, apparently well but for mild arthritis One sister, died in infancy,?cause Husband, died, 54, heart attack One daughter, age 33, migraine headaches, otherwise well One son, 31, headaches One son, 27, well 3

6 PERMISSION FOR TREATMENT OF CHILDREN Patient s Full Name: (Last) (First) (Middle) Patient s Date of Birth: / / Name of Parent/Legal Guardian: If I can t bring my child to a medical/behavioral health or dental appointment, I give permission for the person(s) listed below to go with my child to visits at Keystone Health Center. He/she can also approve treatment for my child during the visit, including shots and minor dental and medical procedures. Name: _Relationship to Patient: Name: _Relationship to Patient: Name: _Relationship to Patient: Please Note: Sometimes, the provider may decide that a parent must be present for certain dental procedures: Extractions, Root Canal s, Surgical procedures, Nitrous visits and Operating Room visits. This permission remains in effect until revoked in writing. Parent/Guardian Signature Witness Signature Date Date Staff Initials 7/30/18 ksw

7 Keystone Vaccine Policy Statement We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives. We firmly believe in the safety of our vaccines. We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics. We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities. We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some forms of the influenza vaccine, does not cause autism or other developmental disabilities. We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health-care providers, and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians. Trusted information can be obtained here:

8 Keystone Health Vaccine Schedule Birth 2mo 4mo 6mo 12mo 15mo 18mo 4-6yr 10yr 11yr 16-18yr Hep B Pediarix Prevnar Rotavirus Dtap Hib Kinrix Hep A MMR Varicella Meningococcal Tdap HPV *for boys and (Ages (will only need 3 rd girls* 9-26) dose if started after age 15) MMR-V Men B Pediarix- Dtap, IPV, and Hep B Kinrix- Dtap and IPV MMR-V- MMR and Varicella Updated 8/2018

9 As a Community Health Center, our mission is to take care of people no matter what their race, ethnicity or income. This survey will help us know if we are helping all kinds of families within our community. Please fill in the information below to best tell us about you and your family. Race- relates to a persons appearance such as skin color: White/Caucasian Black/African American Asian American Indian Native Hawaiian Other Pacific Islander Multi-racial Ethnicity- relates to nationality and culture: Latino/Hispanic Non Latino Do you live in public housing: Yes No Family Annual Family Income Size 1 $12,140 and below $18,210 and below $24,280 and below $24,281 and above 2 $16,460 and below $24,690 and below $32,920 and below $32,921 and above 3 $20,780 and below $31,170 and below $41,560 and below $41,561 and above 4 $25,100 and below $37,650 and below $50,200 and below $50,201 and above 5 $29,420 and below $44,130 and below $58,840 and below $58,841 and above 6 $33,740 and below $50,610 and below $67,480 and below $67,481 and above 7 $38,060 and below $57,090 and below $76,120 and below $76,121 and above 8 $42,380 and below $63,570 and below $84,760 and below $84,761 and above 9 $46,700 and below $70,050 and below $93,400 and below $93,401 and above 10 $51,020 and below $76,530 and below $102,040 and below Revised $102,041 and above