Information Needed to Complete a Chart

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New Patients

Information Needed to Complete a Chart

1. PATIENT REGISTRATION FORM

a. General Information

2. SIGNATURE HIPAA

a. Privacy Policy brochure

3. SIGNATURE A.O.B./R.O.I.

a. Assignment of Benefits (insurance information)

b. Release of Information (in case of referrals)

4. INSURANCE INFORMATION

a. Medicaid/Medicare/Private Insurance/Workman's Compensation/Motor Vehicle

To be qualified for direct services offered through the Tribal Health Department you will need to

provide proof or copies of:

1. TRIBAL ENROLLMENT

a. Certificate of Indian Blood (CIB) or other verifiable Tribal document from a Federally

recognized Tribe acknowledging membership or descent

2. GOVERNMENT ISSUED PHOTO ID

a. Driver's license, passport, other

To be qualified for all services offered through the Tribal Health Department, including PRC

funds, you will need to provide proof or copies of :

1. TRIBAL ENROLLMENT

a. Certificate of Indian Blood (CIB) or other verifiable Tribal document from a Federally

recognized Tribe acknowledging membership or descent

2. GOVERNMENT ISSUED PHOTO ID

a. Driver's license or other government-issued photo ID such as a passport

3. BIRTH CERTIFICATE/PATERNITY PAPERS-AFFIDAVIT

4. SOCIAL SECURITY CARD

a. To verify social security number

5. PROOF OF RESIDENCY

Southern Ute Health Center (970) 563-4581

Fax# (970) 563-0206

SOUTHERN UTE HEALTH CENTER

PO BOX 899

IGNACIO, CO 81137

(970) 563-4581

Dear Prospective Patient,

We would like to welcome you to the Southern Ute Health Center. The Southern Ute Health

Center is an outpatient facility, opened October 1978, replacing the Indian Health Services

Clinic, which had served the reservation since 1955. The Health Center provides comprehensive

clinical and community health services to members of the Southern Ute Indian Tribe as well as

members of other federally recognized tribes residing in the area. Inpatient and specialty services

are also available via purchased/referred care (PRC) referrals. Contact the referral services office

to determine your eligibility for purchased/referred care services.

The Health Center does NOT provide emergency services. Patients with emergencies occurring

outside of regular business hours should call 911. Patients with urgent (non-emergent or non-life

threatening) medical needs occurring outside of regular business hours may reach the triage

nurse by contacting our main phone number (970) 563-4581, or toll free (877) 215-9635.

This package includes the following: 1. Patient Information Form, 2. Health Summary

Questionnaire, 3. Patient Eligibility, 4. Release of Information, 5. Assignment of Benefits, 6.

Privacy Act Form, 7. Notice of Privacy Practices, 8. Notice of Privacy Practices Acknowledgement

Form, 9. Consent of Parent or Legal Guardian or Other Person Who Has Primary Responsibility

for the Care of a Child. If you are eligible for Medicare, you are required to complete the Medicare

Secondary Payer Questionnaire.

When an initial visit is authorized and in cases where eligibility is not in question, but proof of

certification is lacking, a thirty-day grace period may be granted. If proof is not provided within

thirty (30) days, no further services will be provided.

An individual must apply for and use all available and/or accessible resources including but

not limited to:

•

Medicare

Medicaid

Other state or federal health programs

Veterans Administration (VA)

Private Insurance

Please see the following page for further information on Alternate Resources.

Please feel free to share with us any questions, concerns, or suggestions you may have. It is our hope that

by working together we can achieve the optimal level of healthcare for you, your family, and for all we

serve.

Respectfully Yours,

Southern Ute Health Center Staff

Alternate Resources

The Southern Ute Health Center (SUHC) and Southern Ute Indian Tribe (SUIT) policies require

that you apply for and use alternate resources for which you are eligible. Alternate Resources are

other sources of health care or health care benefits such as the First Health Colorado (Medicaid),

Market Place, Medicare, Private Insurance, Veterans Insurance etc. Alternate Resources pay for

and can be a source of health care services that SUHC is unable to provide. The use of Alternate

Resources enables SUHC to provide more health care services to our patients. All patients

eligible for the Health First Colorado plan, Market Place, or Medicare Savings

Programs/Limited Income Subsidies (LIS) are required to apply and show proof of acceptance or

denial. If denied, patients must reapply every 6 months.

Assistance with alternate resource applications is available through the Health Benefits

Coordinators.

First Health Colorado (Colorado Medicaid)

The following documents are required when applying for the First Health Colorado Plan:

Household members, social security number, employer, and income information for everyone in

the home, tribal affiliation.

You can apply for Colorado Medicaid online at: Colorado.gov/PEAK

You can apply for New Mexico Medicaid online at: https://www.yes.state.nm.us/

Market Place Plan

The following is required when applying for the Market Place Plan: Same as First Health

Colorado, Internet with valid Email address

Assistance with applying for Alternate Services

Please contact the health benefits coordinator for assistance with applying for alternate health

services: 970-563-2203.

I understand that under federal law, I have a responsibility to apply for and maintain any

Alternate Resources that I qualify to receive and that failure to comply can result in the loss of

access to and payment for health services that the SUHC offers. I understand that I will not be

able to receive services with the Southern Ute Health Center, Pharmacy, Dental, Optometry

and Audiology and, my chart will be inactivated and if I fail to apply.

Signature (Parent or Guardian if Minor):

Date:

Southern Ute Health Center

69 Capote Drive

Ignacio, CO. 81137

(970) 563-4581

Date:

HRN #

DEMOGRAPHIC INFORMATION

Name: (Last) _ _ _ _ _ _ _ _ _ _ (First) ____________________ (Middle)

Is this your legal name? Yes

Marital Status: Single

If not, what is your legal name?_ _ _ _ _ _ _

Married

Date of Birth:

Divorced

Separated

Widowed

Place of Birth:

Social Security No:

Gender: Female

Male

Mailing Address:

City:

State

ZIP

Physical Address:

City:

State

ZIP

How long at this address?

Religious Preference:

Home Phone:

Internet Access? Yes

Cell Phone:

Work/Other Phone:

Where? Home

Cell

Work

Email Address:

Do we have permission to email you surveys? Yes

Do you have an advanced directive? Yes

If yes, is it a : Power of Attorney

If yes, please provide a copy.

Living Will

If no, would you like information about advanced directives?

What is your ethnicity?

Yes

Race?

Primary language spoken in the home?

Tribal Information

Are you enrolled in a federally recognized tribe? Yes

If no, are you a descendent? Yes

If yes, where are you enrolled (Tribal Affiliation)?

Employer Information

Occupation:

Employer Address:

Employer:

City:

State

ZIP

Mother’s Information

MAIDEN Name: First

Middle

Where was she born? City

State

Employer:

Last

Where is she enrolled?

Work Number:

Employer Address:

City/State/Zip:

What number(s) can mother be reached?

Father’s Information

Name: First

Middle

Where was he born? City

Last

State

Employer:

Where is he enrolled?

Work Number:

Employer Address:

City/State/Zip:

What number(s) can father be reached?

Spouse Information

Name: First

Middle

Employer:

Last

Work Number:

Employer Address:

City/State/Zip:

What number(s) can spouse be reached?

Emergency Contact

Name:

Relationship:

Address:

Phone Number:

Next of Kin – Separate from Emergency Contact

Name:

Relationship:

Address:

Phone Number:

Military Service

Have you ever served in the United States Military? Yes

If yes, list the branch, dates, and type of discharge for all active duty.

Branch

From:

MM/DD/YYYY

To:

MM/DD/YYYY

Type of Discharge

Contract Health Service

I understand that I am required to provide proof of residency, meet medical priority requirement,

exhaust all alternate resources, and meet notification requirements to be eligible for contract health

services with the Southern Ute Tribal Health Department

ANY FALSIFICATION OF INFORAMTION MAY BE REASON FOR DENIAL OF

SERVICES OR ELIGIBILITY

Patient, Parent, or Legal Guardian Signature:

Date:

Patients under 18 years of age must be accompanied by a parent or legal guardian to be seen for

medical appointments.

Benefits Coordinator General Questionnaire

Do you currently have insurance coverage? Yes

Medicaid:

Medicare:

Worker’s Compensation:

If yes, which ones:

Private Insurance:

VA:

Motor Vehicle:

Insurance:

Policy number:

Group Number:

Insurance:

Policy number:

Group Number:

Insurance:

Policy number:

Group Number:

Are there any children in the home under the age of 18 (19 if full-time student) who does not have

health insurance? Yes

Have you applied for Medicaid and been denied? Yes

letter.

Would you like help applying for Medicaid? Yes

Are you 65 years of age or older? Yes

If yes, do you have Medicare? Yes

If yes, please provide denial

If yes, how can we contact you?

Would you like information on Medicare Part D (Pharmacy)? Yes

Are you disabled? Yes

If yes, have you applied for disability? Yes

If yes, what is the status of your application? Approved

Denied

Unknown

The information provided is true to the best of my knowledge. I authorize my insurance benefits to be paid

directly to the physician or group. I understand that I am financially responsible for any balance. I also authorize

the Southern Ute Tribal Health Department and its divisions or insurance company to release any information

required in the processing of my claim.

Patient/Guardian Signature:

Health Center Review (OFFICE USE ONLY): Approved

Health Center Office Signature:

Date:

Denied

Date:

Patient Eligibility

Patients MUST provide proof of eligibility at the time of visits at the Southern Ute Health

Center. When an initial visit is authorized and in cases where eligibility is not in question, but

proof of certification is lacking, a 30-day grace period will be granted.

Examples of Proof of Eligibility:

1. Certificate of Indian Blood issued by the Bureau of Indian Affairs or the US Department

of the Interior.

2. Proof of descendent or a copy of parent's Certificate of Indian Blood will cover minors

up to 18 years of age.

3. Letter from enrolling Tribal Office or BIA Agency showing recognition of decadency.

If proof is not provided within the 30-day grace period, the patient will be sent two reminders, each

reminder will be sent in 30-day increments. If documentation is not providedafter the 90 days, the patient

will be inactivated and may be billed for the health care servicesprovided.

I have read and understand the above statements:

Signature of Patient

Date

Patient Registration Clerk Signature

Date Informed

Patient Registration Clerk Signature

Date of Reminder #1

Patient Registration Clerk Signature

Date of Reminder #2

Release of Information and Assignment of Benefits

Authorization for Health Care

The undersigned voluntarily agrees to treatment and services that his or her physician deems necessary.

Release of Information for Treatment and Billing Services

I understand and acknowledge that the SUHC may release information to other providers for the

provision, coordination, or management of my health care and related services. The SUHC may

disclose all or any reasonable part of the patient's medical record to include information pertaining

to medical history, mental or physical condition, alcohol/drug abuse and psychiatric diagnosis to

any person or entity for the purpose of billing all or part of the health care charges to include but

not limited to any person, insurance companies, employer, preadmission review, utilization

review, evaluation, financial audit, or any other purposes. I understand that this authorization will

remain in effect as long as health care services are rendered.

Private Insurance

The Southern Ute Health Center (SUHC) may disclose all or any part of the patient's records to any

person or corporation which is, or may be, liable under a contract to the health clinic, the patient, a family

member and/or employer of the patient for all or part of the health clinic's charges, including, but not

limited to, the health clinic or medical services companies, insurance companies, worker's compensation

carriers, welfare funds, or the patient's employer.

I hereby assign to SUHC such insurance benefits, if any that I may have pertaining to payment for

medical services and supplies furnished to me by the SUHC. I authorize payment of such benefits directly

to SUHC. I understand that this assignment applies to outpatient, physician services furnished to me,

cover previous visits, and will continue until revoked.

Medicare and Medicaid

I hereby assign to the Southern Ute Health Center such insurance benefits, if any, that I may have

pertaining to payment for medical service and supplies furnished to me by the SUHC. I authorize

payment of such benefits, if any, directly to SUHC. I understand that this assignment applies only to

medical services and supplies furnished to me during the period designated. The release of clinical

information required to substantiate appropriate insurance claims is authorized.

Patient Signature

Date

Patient Representation Clerk Signature

Date

HIPAA Notice of Privacy Practices

Southern Ute Tribal Health Department

69 Capote Dr.

Ignacio, CO 81137

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW CAREFULLY.

This Notice of Privacy Practice describes how we may use and disclose your protected health information (PHI) to carry

out treatment, payment or health care operations (TPO), and for other purposes that are permitted by law. It also

describes your rights to access and control your protected health information. “Protected health information” is

information about you, including demographic information, that may identify you and that relates to your past, present or

future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff, and others

outside of our office that are involved in your care and treatment for the purpose of providing health care

services to you, to pay your health care bills, to support the operation of the physician’s practice, and any

other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage

your health care and any related services. This includes the coordination or management of your health care

with a third party. For example, we would disclose your protected health information, as necessary, to a

home health agency that provides care to you. For example, your protected health information may be

provided to a physician to whom you have been referred to ensure that the physician has the necessary

information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care

services. For example, obtaining approval for a hospital stay may require that your relevant protected health

information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information to support

the business activities, training of medical students, licensing, and conducting or arranging for other business

activities. For example, we may disclose your protected health information to medical school students that

see patients in our office. In addition, we may use a sign-in sheet at the registration desk where you will be

asked to sign your name and indicate your physician. We may also call you by name in the waiting room

when your physician is ready to see you. We may use or disclose your protected health information, as

necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your

authorization. These situations include: as Required by Law, Public Health issues required by law,

Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements:

Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research:

Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required

Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary

of the Department of Health and Human Services to investigate or determine our compliance with the

requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization,

or opportunity to object unless required by law.

You may revoke the authorization, at any time, in writing, except to the extent that your physician or the

physician’s practice has taken action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however,

you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable

anticipation of, or in use in, a civil, criminal, or administrative action or proceeding, and protected health

information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may

ask us not to use or disclose any part of your protected health information for the purpose of treatment,

payment, or healthcare operations. You may also request that any part of your protected health information

not be disclosed to family members or friends who may be involved in your care or for notification purposes

as described in this Notice of Privacy Practices. Your request must state the specific restrictions and to

whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is not in

your best interest to permit use and disclosure of your protected health information, your protected health

information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request the receive confidential communications from us by alternative means

or at alternative location. You have the right to obtain paper copy of this notice from us, upon request,

even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny

your request for amendment, you have the right to file a statement of disagreement with us and we may

prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your

protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You

then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights

have been violated by us. You may file a complaint with us by notifying our privacy contact of your

complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal

duties and privacy practices with respect to protected health information. If you have any objections to this

form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone

Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.

Print Name: ___________________________ Signature: ______________________________

Date:_________

Privacy Act Signature Form

I understand that the information given by me and/or collected and stored in my health record is

necessary for the Southern Ute Health Center staff to provide services for my health and

wellbeing. Furthermore, I have been informed that my health record or any portion of my health

record shall not be disclosed to another agency or person without my consent.

I have read the Privacy Act Notice. I have been informed that my record is or will be kept in the

Health and Medical Records System at:

Southern Ute Health Center

69 Capote Drive

Ignacio, CO 81137

(970) 563-4581

Note: Psychotherapy notes will either be maintained at the Southern Ute Health Center or at a

location the contracted provider deems fit.

Signature of Patient

Signature of Guardian for Minor or Court

Ordered Guardian

Signature of Patient Registration Clerk

Date

Consent of Parent of Legal Guardian or Other Person Who

Has Primary Responsibility for the Care of a Child

Name of Child

Date of Birth

I (We),

have read the Southern Ute Health Center's Consent Form to arrange for or to provide the

following health services for the above identified child:

1. Health care including medical examinations, routine laboratory studies, radiographic

procedures, immunizations, and skin tests.

2. Dental care including dental examinations, preventive use of fluoride and necessary

emergency dental care including radiographs.

3. Mental health services including evaluations and treatment as necessary.

4. Emergency healthcare for accidents or illness.

5. Transportation of the child to and/or from another health facility for these services.

□ I (We) hereby give consent for all the above services.

□ Exceptions or Special Instructions:

I (We) designate the following individual(s) to bring the named child in for care:

Relationship:

Signature:

Address:

City/St/Zip:

Relationship:

Date:

Valid Until (max 1 year):

(if blank, valid for 1 year)

SOUTHERN UTE HEALTH CENTER

Authorization to Release Information TO the Southern Ute Health Center

Name:

Last four of Social

Security #:

INFORMATION IS TO BE DISCLOSED BY:

Name of Organization/Facility

Address

City, State, Zip

Phone/Fax

Date of Birth:

Daytime Phone#

INFORMATION IS TO BE PROVIDED TO:

Name of Organization/Facility

Southern Ute Health Center

Address

69 Capote Dr., PO Box 899

City, State, Zip

Ignacio, CO 81137

Phone/Fax

970-563-4581/970-563-0206

PURPOSE OF THIS DISCLOSURE:

□ Further Medical Care

□ Disability Determination

□ Legal Investigation

□ Payment of Claim/Benefits

□ Personal Use

□ Other (specify)

INFORMATION TO BE DISCLOSED FROM MY HEALTH RECORD (check appropriate boxes):

□ Only information related to (specify)

□ Only the period of events from

□ Other (specify)

□ Entire Record

If you would like any of the following sensitive information disclosed, check the applicable box(es) below:

□ Alcohol/Drug Abuse Treatment/Reference

□ Sexually Transmitted Disease

□ Psychotherapy

□ HIV/AIDS Related Treatment

□ Mental Health (Other than Psychotherapy Notes)

YOUR RIGHTS REGARDING THIS AUTHORIZATION

Right to inspect or receive a copy of the information to be used or disclosed: I understand that I have the right to inspect or receive

a copy of the health in formation I have authorized lo be us ed or disclosed

Right to receive a copy of this authorization: I understand that if I agree to sign this authorization, which I am not required to do, I

may request a signed copy of the form.

Right to refuse to sign this authorization: I understand that I am under no obligation to sign this form and the person(s) and/or

organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment or

eligibility for health care benefits based on my decision to sign this authorization.

Right to withdraw this authorization: I understand that written notification is necessary to cancel this authorization.

Expiration Date: This authorization is effective for one (1) year from the date signed unless otherwise indicated.

Date (Optional)

Patient or Legal Representative Signature/Relationship

Date of Signature

SOUTHERN UTE HEALTH CENTER

Authorization to Release Information FROM the Southern Ute Health Center

Name:

Last four of Social

Security #:

INFORMATION IS TO BE DISCLOSED BY:

Name of Organization/Facility

Southern Ute Health Center

Address

69 Capote Dr., PO Box 899

City, State, Zip

Ignacio, CO 81137

Phone/Fax

970-563-4581/970-563-0206

Date of Birth:

Daytime Phone#

INFORMATION IS TO BE PROVIDED TO:

Name of Organization/Facility

Address

City, State, Zip

Phone/Fax

PURPOSE OF THIS DISCLOSURE:

□ Further Medical Care

□ Disability Determination

□ Legal Investigation

□ Payment of Claim/Benefits

□ Personal Use

□ Other (specify)

INFORMATION TO BE DISCLOSED FROM MY HEALTH RECORD (check appropriate boxes):

□ Only information related to (specify)

□ Only the period of events from

□ Other (specify)

□ Entire Record

If you would like any of the following sensitive information disclosed, check the applicable box(es) below:

□ Alcohol/Drug Abuse Treatment/Reference

□ Sexually Transmitted Disease

□ Psychotherapy

□ HIV/AIDS Related Treatment

□ Mental Health (Other than Psychotherapy Notes)

YOUR RIGHTS REGARDING THIS AUTHORIZATION

Right to inspect or receive a copy of the information to be used or disclosed: I understand that I have the right to inspect or receive

a copy of the health in formation I have authorized lo be us ed or disclosed

Right to receive a copy of this authorization: I understand that if I agree to sign this authorization, which I am not required to do, I

may request a signed copy of the form.

Right to refuse to sign this authorization: I understand that I am under no obligation to sign this form and the person(s) and/or

organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment or

eligibility for health care benefits based on my decision to sign this authorization.

Right to withdraw this authorization: I understand that written notification is necessary to cancel this authorization.

Expiration Date: This authorization is effective for one (1) year from the date signed unless otherwise indicated.

Date (Optional)

Patient or Legal Representative Signature/Relationship

Date of Signature

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to

call and request the result of tests, procedures, and financial information. Under the requirements for H.I.P.A.A.

we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your

medical information, any diagnostic test results, and/or financial information released to any family members you

must sign this form.

You have the right to revoke this consent, in writing, except where we have already made disclosures in

reliance on your prior consent.

I authorize Southern Ute Tribal Health Department to

release my records and discuss any information requested to

the following individuals.

Relation to Patient:

Authorization Regarding Messages(please check all that apply)

I authorize you to leave a detailed message on my home or cell number regarding appointments

I authorize you to leave a detailed message on my home or cell number regarding

medicaltreatment, care, test results or financial information

I authorize you to leave a message with anyone who answers the phone

Messages may only be left with

Patient Name (PLEASE PRINT)

Date

Patient Signature

HEALTH QUESTIONNAIRE

Confidential Data

Name:

Date of Birth:

Date:

Reason for Visit and Symptoms:

Name:

Other Medical Personnel Involved in Your Care

Phone number:

Reason:

Allergen Name

Reaction

Medication

Allergies/Intolerances

Start Date

Medication - List all prescription medications you currently take.

Start Date

Strength

How Often

Reason

Supplements - List all vitamins, hormones, alternative remedies or over the counter medications you

Medication

Start Date

use.

Strength

How Often

Reason

Preventative Care - List date of last test or screening

Date of last test or screening

Test

Colonoscopy:

Dental examination:

DEXA (bone density):

Eye Exam:

Male Patients

PSA laboratory test:

Rectal/prostate exam:

Testicular exam:

Date of last test

Please check below symptoms if applicable

□ Diminished libido

□ Difficulty obtaining or maintaining an

erection

□ Urinary: decreased flow or delayed flow

□ Urethral discharge

HEALTH QUESTIONNAIRE

Confidential Data

Name:

Date of Birth:

Female Patients

Date:

Date of Last Exam/Test

Menstrual History

Breast exam:

Age of onset:

Mammogram:

Date of last period:

Length of cycle:

Pap smear:

□ regular □ irregular

Rectal examination:

Days of flow:

Flow Description:

SEXUAL HISTORY

□ Pain during or after intercourse

□ Bleeding after intercourse

□ Diminished libido

□ Infertility

□ Heavy

□ Pain

□ Moderate

□ Cramps

□ Light

□ Clots

□ Menopause Symptoms (flushing, moodiness,

changes in cycle, other)

No. of pregnancies

Live births

Age of menopausal onset

Miscarriages

Abortions

Birth control method:

HEALTH QUESTIONNAIRE

Confidential Data

Name:

Date of Birth:

Health History

Date:

Are you being treated for, or have you had any of the following health conditions? Please check

if applicable. Additional space is provided below for details or other health conditions not listed.

□ Peripheral vascular

□ Allergies

□ Defibrillator

□ High blood pressure

disease

□ Alcohol

□ Pleurisy

□ Dementia

□ HIV/AIDS

Problems

□

Anemia

□

Depression

□

Hyperthyroidism

□

Pneumonia

□

Aneurysm

□

Diabetes

□

Hypothyroidism

□

Prostate problems

□

Anxiety

□

Diarrhea

□

Irritable bowel

□

Seizure disorder

□

Diverticulosis or

diverticulitis

□

Arthritis

Kidney disease

□

Asthma

Atrial

fibrillation

Bleeding

problems

□

Eating disorder

□

Kidney failure

□

Sexually

transmitted

disease(s)

Sleep apnea

□

Emphysema

□

Kidney stones

□

Stents

□

Fertility

issues

□

Low back pain

□

Stroke

□

Blood clots

□

GERD

□

Lupus (SLE)

□

TIA

□

Blood

transfusion

Bronchitis

Cancer

□

Glaucoma

□

Tremors

□

Goiter

Gout

□

Mental Illness/mood

disorder

MSRA infections

Narcolepsy

□

Tuberculosis

Urinary

□

Headaches

□

Neuropathy

□

Valvular disease

□

Heart attack

□

Nervous System

disease

□

Varicose veins

□

Type:

□

CHF

Crohn's

□ Heart

□

□ Obesity

disease

□ Colitis

□ Heart Failure

□ Pacemaker

□ Constipation

□ Hemorrhoids

□ Palpitations

□ COPD

□ Hepatitis

□ Peptic ulcer(s)

List additional information and other health conditions not listed above:

Weight

problems

HEALTH QUESTIONNAIRE

Confidential Data

Name:

Date of Birth:

Past Hospitalizations/Procedures/Surgeries

List surgical procedures, reasons for hospitalizations and the year.

Type

Approximate Date Type

Date:

Approximate Date

Immunizations: List date of last injection and if record is attached.

Injection

Date

Record

Injection

Date

Attached?

Gardasil

□ Yes □ No

Pneumonia

□ Yes □ No

Hepatitis A

□ Yes □ No

Polio

□ Yes □ No

Hepatitis B

□ Yes □ No

Tetanus

□ Yes □ No

Influenza

□ Yes □ No

T-dap

□ Yes □ No

MMR

□ Yes □ No

Typhoid

□ Yes □ No

Meningitis

□ Yes □ No

Zostavax

□ Yes □ No

Social, Safety, Cultural, Communication History

Smoking Status □ Current daily smoker □ Current someday smoker □ Former smoker

□ Never smoker

If current or quit within 12 months, □ Cigarettes □Cigars □ Pipe □ Smokeless

If current or quit within 12 months, Smoking Cessation Counseling □ Yes □ No

Preferred language:

Ethnicity □Hispanic/Latino □ Not Hispanic/Latino

Race: □ White □ African American □ American Indian/Alaskan □Asian □Hawaiian/Pacific

Islander □ Other

Relationship status: □ Married □ Single □ Widowed □ Divorced □ Partnered □ Other

drinks per d ay/week/month

Alcohol? □ Yes □ No □ Rarely Amount

Amount

cups per d ay/week/month

Caffeine? □ Yes □ No

Do you/or have you had a problem with drug use □ Yes □ No If yes, list type

frequency

Do you exercise? □ Yes □ No If yes, list type

Do you have children? □ Yes □ No If yes, how many?

Seatbelt usage? □ Yes □ No Percent of time worn:

Have you been hit or threatened in the past year? □ Yes □ No

Are there cultural or religious beliefs that need to be considered in your care? □ Yes □ No

If yes, explain:

Potential barrier to learning: □ none □ inability to understand English

□ Language (if other than English) □ blind □ poor vision □ deaf □ decreased hearing

□ unable to talk □ unable to read □ memory loss

Learns best by: □ reading □ verbal instruction □ practicing □ talking □ watching □ other

Do you have a:

Durable Power of Attorney? □Yes □ No If yes, list person(s):

Healthcare representative? □Yes □ No If yes, list person(s):

Living Will? □Yes □ No

If yes, list person(s):

DNR Do Not Resuscitate? □ Yes □ No

Would you like information on any of the above? □ Yes □ No

HEALTH QUESTIONNAIRE

Confidential Data

Seizures

Gout

Anemia

Alcoholism

Mental illness

Migraine

Glaucoma

Kidney disease

Arthritis

Date:

Tuberculosis

COPD

Asthma

Cancer

Diabetes

High cholesterol

Heart disease

Cause of death

Age at death

Deceased

Mark the

appropriate

box

Alive and well

Family

History

High blood pressure

Date of Birth:

Stroke

Name:

Father

Paternal

Grandfather

Paternal

Grandmother

Mother

Paternal

Grandfather

Paternal

Grandmother

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Spouse

Additional Comments or Information:

Person completing form

Signature

Date

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.