FREE CLINIC OF THE TWIN COUNTIES PATIENT APPLICATION
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1 FREE CLINIC OF THE TWIN COUNTIES PATIENT APPLICATION Clinic Use Only: Paid: Clinic card expires: / / Income Verification: Tax Form W2 Letter Other Income NAME: (First) Middle LAST Former Last Name ADDRESS CITY STATE ZIP CODE DOB SSN MARITAL STATUS: Single Married Divorced Legally Separated Never Married Widowed SEX: Female Male HOME PHONE: - - CELL - - WORK - - ( Pease provide for portal) CONTACT PERFERENCE PATIENT PORTAL REGISTRATION Yes NO VERTERAN CONSENT TO TEXT ARE YOU HOMELESS ARE YOU EMPLOYED If yes, where? Pay Rate How did you hear about us? HOW MANY PEOPLE LIVE IN YOUR HOME ARE YOU LIVING WITH RELATIVES HOUSEHOLD INCOME DO YOU GET FOOD STAMPS HOW MUCH PRIMARY LANGUAGE SECOND LANGUAGE (if any) PREFERRED PHARMACY CITY OF PHARMACY RACE ETHNICITY RELEASE MEDICATION/MEDICAL INFORMATION Yes NO NAME: ADRESS CITY STATE EMERGENCY CONTACT NAME PHONE ADDRESS CITY STATE ZIP APPLICANT SIGNATURE DATE OFFICE SIGNATURE DATE
2 FREE CLINC OF THE TWIN COUNTIES INFORMATION WITH TERMS AND CONDITIONS FOR PROSPECTIVE AND RENEWAL PATIENTS CRITERIA: The Free Clinic of the Twin Counties works hard to provide patients with quality medical care. To receive services at TFC (The Free Clinic) you will need to meet some criteria: You must have lived in the Twin County area (Carroll, Grayson, or City of Galax) for a minimum of six months. Household income must be 200% or less of the Federal Poverty Level. You must be completely uninsured (No Medicare, Medicaid, Veteran s Benefits, or Private Insurance). WHERE TO APPLY: You may apply for services at: THE FREE CLINIC OF THE TWIN COUNTIES 140 Larkspur Lane, Suite C Galax Va How to apply: You will need to complete a short application providing us with information about yourself and your household. After you are determined eligible for services, TFC can schedule your first appointment if you need to see one of our providers. Eligibility for services is for a 12 month period and eligibility will need to be re-examined every 12 months. When to Apply: Applicants may apply Tuesday through Thursday, 9:30-11:30 am. & 1:00-4:00 pm. NOTE: WE DO NOT PRESCRIBE CONTROLLED SUBSTANCES INCLUDING NARCOTICS AND BENZODEAZIPAMS ( i.e. Xanax, Klonopin, Atavan, Valium). Proof of Income: When you come to the clinic to apply for services, please bring with you at least 1 form showing Proof of Income: Bank Statements, Notices from Social Security, Paycheck Stubs, Food Stamp notices, Child Support Information, Alimony Check/ Copy of Court Order, etc. TFC will take into consideration total household income so you will be required to bring proof of total household income. Termination: Eligibility for services through TFC will end if you begin to receive medical insurance of any type or if your income should increase beyond the stated limits. If you are found to have insurance while you are a FREE CLINIC patient, your services will be terminated.
3 FREE CLINIC OF THE TWIN COUNTIES PROOF OF INCOME Pay Stubs Provide either the most recent with Year to Date income listed W-2 Form Or Income Tax Return for most current calender year Unemployment Notice From VEC ( Virginia Employment Commission) Statement of Social Security Benefits Or other benefits Food Stamp - Letter of Eligibility Alimony Check Or copy of Court Order Child Support Information or Court Order
4 FREE CLINIC OF THE TWIN COUNTIES HEALTH QUESTIONAIRE NAME: DOB: PAST MEDICAL HISTORY HEAD Trauma EYES Blindness Cataracts Glaucoma Wear Glasses/Contacts EARS Hearing Aid NOSE/SINUSES Allergic Rhinitis Sinus Infection MOUTH/THROAT/TEETH Dentures Partial Plates Blood Type A AB B O CARDIOVASCULAR Aneurysm Angina DVT Dysrhythmia Hypertension Murmur Myocardial Infarction Other Heart Disease Explain: SKIN Dermatitus Mole(s) Other Skin Condition(s) Psoriasis PSYCHIATRIC Anxiety Bipolar Depression Hallucinations, Delusion Suicidal Ideation Suicide Attempts Positive Negative Unknown RESPIRATORY Asthma Bronchitis COPD Bronchitis/Emp Pleuritis Pneumonia GASTROINTESTINAL Cirrhosis GERD Gallbladder Disease Heartburn Hemorrhoids Hepatitis Hiatal Hernia Jaundice Ulcer GENITOURINARY Hernia Incontinence Nephrolithiasis Other Kidney Disease STDs UTI(s) MUSCULOSKELTAL Arthritis Gout M/S Injury NEUROLOGICAL Epilepsy Seizures Severe Headaches Stroke TIA ENDOCRINE Goiter Hyperlipidemia Hypothyroidism Thyroid Disease Type I DM Type II DM
5 HEME/ONC Anemia Cancer INFECTIOUS AIDS HIV STDs Tuberculosis (dz) Tuberculosis ( exposure) PAST SURGICAL HISTORY COMMON SURGERIES: Aneurysm Repair Appendectomy Laminectomy Back Surgery Bariatric Surgery Bilateral Tubal Ligation Breast Resection/Mastectomy Carotid Endarterectomy/Stent Carpal Tunnel Release Surgery Reverse Tubal Ligation Cataract/Lens Surgery Cesarean Section Cholystectomy/Bile Duct Surgery Dilation & Curettage Hemorrhoid Surgery Hip Arthroplasty Hip Replacement Hysterectomy Inguinal Hernia Repair Knee Arthroplasty LASIX Nasal Surge PTCA/PCI Pacemaker/Defibrillator Prostate Surgery Prostatectomy Rotator Cuff Surgery Sinus Surgery Skin Cancer Excision Spinal Fusion TAH-BSO Tonsillectomy/Adnoidectomy Vasectomy Gallbladder Kosh Punch Placement SOCIAL HISTORY TABBACCO USAGE Current Daily Smoker DRUG ABUSE CARDIOVASCULAR Former Smoker IVDU Eat Healthy Meals Never Smoker Illicit Drug Use Regular Exercise No Illicit Drug Take Daily Aspirin ALCOHOL Do Not Drink Drink Daily Frequent Drinker Hx of Alcoholism Occasional Drinker SAFETY Household Smoke detectors Keep Firearms in Home SEXUAL ACTIVITY Exposure to STI Homosexual Encounters Not Sexually Active
6 Safe Sex Practices Sexually Active CURRENT MEDICATIONS Name : Dosage: DRUG ALERGIES Please List any strong family diseases: Arthritis Asthma Bleeding Disorder COPD Diabetes Heart Disease Seizure Disorder Tuberculosis Colon Cancer Uterine Cancer Ovarian Cancer FAMILY HISTORY Heart Attack High Cholesterol Hypertension Mental Illness Osteoporosis Stroke Alcoholism Drug Abuse Thyroid Disorder Breast Cancer Other Cancer
7 WOMEN: Age of Menstruation History of Abnormal PAP Smear History of irregular Menses Age of Menopause History of Fertility Drug Use Unable to become pregnant PREGNABCY HISTORY: Total Pregnancies Full Term Miscarriages Abortions Living MEN: Prostate Trouble Yes No Weak Stream Yes No Use of Viagra or other ED medications Yes No Impotence/Difficulty with Erections Yes No
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SCHNEIDER MEDICAL GROUP, PA Registration Form Instructions (Please Print)
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Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
NEUROSURGERY PATIENT INTAKE FORM
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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Patient Interview Form
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PATIENT INFORMATION FORM
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Name: DOB: Sex: Male Female
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PERSONAL HISTORY CURRENT HEALTH CONDITION
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New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
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Patient Name: Date of Birth:
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Clinic Adult Patient Demographics
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
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Adult Health History
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FROST FAMILY MEDICINE
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
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Patient registration
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An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Medical History Form
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New Patient Information and History Form John K. Dorman, M.D., FACS Diplomate of The American Board of Neurological Surgery 400 Rosalind Redfern Grover Parkway Suite 200 Midland, TX 79701 432 687-2350
Health History Intake Form;
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New Patient History & Intake Form Patient Information Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider: Preferred
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
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Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:
Patient Profile Patient Name: DOB: Address: City: State: Zip: Phone# (H): (W): Other: Email: May Dr. Strong to leave medical information on your answering machine/voicemail? YES NO May Dr. Strong to send
Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
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The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact: