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1 The Priority Care Center A Program of the Humboldt IPA Primary Care Physician: Sec on 1 Demographic Informa on How were you referred: Name (Last, First, M.I.): A.K.A.: Date of Birth: Mailing Address: / / Age: Gender: Male Female Transgender Other City: State: Zip Code: Home Phone: E mail Address: Work Phone: Cell Phone: Do we have permission to contact you via e mail? Yes No Primary Spoken Language: English Spanish Portuguese Other: To which racial or ethnic group(s) do you most iden fy: African American (non Hispanic) Asian/Pacific Islanders Caucasian (non Hispanic) La no or Hispanic Na ve American or Aleut Other: Marital Status: Full name of spouse or significant other: Single Partnered Married Separated Divorced Widowed Employer Name: Employer Address: Occupa on: Employment Status (choose all that apply): Driver s License Number: Full me Part me Self employed Not employed Re red Ac ve Military Sec on 2 Emergency Contact Informa on Contact Name: Rela on to Pa ent: Address: Home Phone: Work Phone: Cell Phone:
2 Sec on 3 Insurance Informa on: if we have a copy of your Ins. card(s) skip this sec on Primary Insurance: Subscriber ID Number: Group Number: Group Name: Complete the following ques ons if the subscriber is someone other than yourself, the pa ent. Subscriber s Name: Address: Subscriber s Date of Birth: / / Rela on to Pa ent: Subscriber s SSN: Secondary Insurance: Subscriber ID Number: Group Number: Group Name: Complete the following ques ons if the subscriber is someone other than yourself, the pa ent. Subscriber s Name: Address: Subscriber s Date of Birth: / / Rela on to Pa ent: Subscriber s SSN: Other Insurance: Subscriber ID Number: Complete the following ques ons if the subscriber is someone other than yourself, the pa ent. Group Number: Subscriber s Name: Address: Subscriber s Date of Birth: / / Group Name: Rela on to Pa ent: Subscriber s SSN: Sec on 4 Consents I hereby cer fy that I am eligible for the health insurance plan I have listed in my registra on form. I, also, cer fy that I have chosen The Priority Care Center to provide me with healthcare services. I understand that, were the aforemen oned statement not true, I would be responsible for any and all charges for the services rendered. Addi onally, if the aforemen oned statement were not true, I agree to pay all charges, in their en rety, and within 90 days of receiving an invoice for services rendered at the Priority Care Center. I understand my rights that are referenced in the no ce of Privacy Prac ces (a copy of this can be made available to you upon request). I give consent to for The Priority Care Center to obtain my prescrip on history. Signature Date / /
3 Name DOB The Priority Care Center A Program of the Humboldt IPA Name: DOB: Gender: M F Primary Care Provider: Preferred Pharmacy: Location: CURRENT MEDICATIONS/SUPPLEMENTS (may bring own list to visit if you prefer) this information may be taken directly from the pharmacy label on the prescription product. Name of Medication Strength of Medication Dosing Instructions Example: Tylenol Example: 500 mg Example: 1 pill three times a day Past Medical History (Check all that apply) Acid Reflux/GERD ADHD Alcoholism Allergies Anemia Anxiety Arthritis Asthma Bleeding Disorders Cancer Allergies Chronic Pain Depression Diabetes Emphysema/Bronchitis/COPD Epilepsy/Seizure Disorder Glaucoma/Cataracts Headaches Hearing Loss Heart Disease High Blood Pressure High Cholesterol Irritable Bowel Kidney Disease Liver Disease Osteoporosis Stroke Thyroid Disease Other: No Known Allergies Medication Allergies List Allergies Environmental/ Seasonal Allergies Latex Allergy Reaction 1
4 Name DOB The Priority Care Center A Program of the Humboldt IPA Past Surgical History Date of Surgery Type of Surgery Family Medical History Members Father Status (Alive/Deceased) Diabetes High blood pressure Heart Disease Mental Illness Cancer (Type) High cholesterol Unknown Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Siblings Children Social History Tobacco Use: Current use: Yes No Past Use: Yes No When did you quit? Type: Cigarettes Cigars Chew E-cigarette Recreational Drug Use: Yes No Type: Marijuana Cocaine Heroin Methamphetamine Other Alcohol Use: Daily 4-5 times per week 1-3 times per week less than one time per week none Type: Beer Wine Liquor Marital Status: Married Separated Divorced Domestic Partnership Single Widow/Widower Living Situation: Own Rent Homeless Other Children: Yes No if yes, do they live with you Yes No Support Network: Spouse/Significant other Family Friends Counselor Other Diet/Exercise: Are you on a special diet? Yes No if yes, what type Do you Exercise? Yes No If yes, how often Daily 3-5 days per week 1-2 days per week less than once per week What type 2
5 Name DOB The Priority Care Center A Program of the Humboldt IPA Do you have an Advance Directive in place? Living Will Durable Power of Attorney Advanced Directive POLST None HEALTH MAINTENANCE Please provide the dates and results of the following immunizations, examinations, and tests to the best of your ability. If you have not had one of these services please indicate (not applicable). All Patients Last Tetanus Booster Within past 10 years More than 10 years ago Last Eye Exam (Dilated or Retinal) Last Hearing Exam Normal Normal Normal Abnormal Abnormal Abnormal Last Dental Exam Normal Abnormal Last Foot Exam Last colonoscopy/ sigmoidoscopy/or stool test Normal Abnormal Last DEXA Bone Scan Normal Abnormal Last Pneumonia Vaccine Flu shot this season? Yes No Women Only Last Pap Smear Normal Abnormal Last Mammogram Date: Normal Abnormal Concerns Please indicate any concerns regarding your health in the space provided v4;jrc
6 Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally by circling your answer. Your answers should be what is true for you and not just what you think the clinician wants you to say. If the statement does not apply to you, circle. NAME: 1. When all is said and done, I am the person who is responsible for taking care of my health. Agree Agree 2. Taking an active role in my own health care is the most important thing that affects my health. Agree Agree 3. I am confident I can help prevent or reduce problems associated with my health. Agree Agree 4. I know what each of my prescribed medications do. Agree Agree 5. I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself. Agree Agree 6. I am confident that I can tell doctor concerns I have even when he or she does not ask. Agree Agree 7. I am confident that I can follow through on medical treatments I may need to do at home. Agree Agree 8. I understand my health problems and what causes them. Agree Agree 9. I know what treatments are available for my health problems. Agree Agree 10. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising. Agree Agree 11. I know how to prevent problems with my health. Agree Agree 12. I am confident I can figure out solutions when new problems arise with my health. Agree Agree 13. I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress. Agree Agree
7 Insignia Health. Patient Activation Measure; Copyright , University of Oregon. All Rights reserved. NAME: PHQ-9 Over the last 2 weeks how often have you been bothered by any of the following problems? not at all several days more than half the days 1. Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way PHQ-9 total score = nearly every day
8 Name: Date of Birth: Global Health Assessment Please respond to each item by marking one box per row. Questions Excellent (5) Very Good (4) In General, would you say your health is In general, would you say your quality of life is In general, how would you rate your physical health? In general, how would you rate your mental health, including your mood and your ability to think? In general, how would you rate your satisfaction with your social activities and relationships? In general, please rate how well you carry out your usual social activities and roles (this includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc. Good (3) Fair (2) Poor (1) Completely Mostly Moderately A little Not at all To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair? In the past 7 days, how often have you been bothered by emotional problems such as feeling anxious, depressed or irritable? How would you rate your fatigue on Average? How would you rate your pain on average? Never Rarely Sometimes Often Always None Mild Moderate Severe Very Severe To be Completed by Staff Subtotal (total score per column) Total Score (add up each of the above)
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