Language
English (US)
Spanish (Latin America)
Intake Paperwork
When you are done, hit the submit button. When you see the green check mark the form is complete. We will be notified when the green check mark appears.
Clinic Date
-
Month
-
Day
Year
What day is your appointment scheduled?
Patient Primary Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Other
Appointment Reason:
*
Medical/Chiropractic/Mental Health
Dental
Have you been to Clinic With A Heart in the last 6 months?
Yes
No
Please describe what you want to discuss with your medical provider?
*
Please describe what you want to discuss with your dental provider?
*
Allergies and Medications
Do you have any drug allergies?
*
No
Yes
What are you allergic to and what is your reaction?
Drug Name
What is your reaction
Allergy 1
Allergy 2
Allergy 3
Are you currently taking any medications, including over the counter medicine and vitamins?
*
Yes
No
What medications do you currently take, including over the counter and vitamins? (If you do not take any medications, write "none" in the first row.)
*
Medication Name
Dosage
How often do you take
Why do you take this medicine
Last dose (date and time)
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Are you taking any other medications; including over-the-counter-meds, vitamins, supplements, etc?
Medication Comments
Consents
Consent
*
Yes
No
I give staff/volunteers at Clinic with a Heart permission to treat me or my minor child.
I understand that I may have up to 3 medical visits every calendar year.
I understand that if I am prescribed medicine, it will be from a limited list of available medications and will be for a maximum of a 60-day supply.
I understand that Clinic with a Heart does not prescribe narcotics or controlled substances.
I understand that medical information I share with Clinic with a Heart will be kept confidential.
I understand I may review Clinic with a Heart's notice of privacy practices and will be provided a copy if requested.
My signature below confirms that I have reviewed and agreed to consent.
*
Yes
No
My typed signature confirms that I have reviewed and agree to the consents.
First Name
Last Name
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Would you like a referral to go get lab work done for a prostate screening test? This would be free to you.
*
Yes
No
Are you interested in a Colon Cancer Screening Test Kit? This would be free to you.
*
Yes
No
We are able to provide free healthcare because of generous donors. Would you be willing to share how Clinic with a Heart has helped you? If so, we would feature you in our monthly newsletters and our social media platforms.
Yes
No
Demographics
If the patient is 18 or younger, who is the parent or legal guardian?
First Name
Last Name
What is the patient's marital status?
*
Please Select
Single
Married
Widowed
Divorced
Other
Please fill out for the patient if the patient is a minor.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in?
*
Lancaster
Saline
Douglas
Other
Primary Phone
*
Phone Type
*
Please Select
Cell
Landline
Work
Is it OK to text this phone?
*
No
Yes
Email Address
example@example.com
Which of the following best describe you? (check all that apply):
*
American Indian/Alaskan Native
Asian
Black
Hispanic or Latino
Middle Eastern
Native Hawaiian
Pacific Islander
White
I prefer not to answer
Other
What language is the patient most comfortable speaking?
*
English
Spanish
I prefer not to answer
Other
How well does the patient speak English?
*
Excellent
Good
Fair
Poor
Not at all
I prefer not to answer
Have you served in the United States Military?
No
Yes
I prefer not to answer
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Does the patient have insurance?
*
None
Medicaid
Have applied for Medicaid
Medicare
Have applied for Medicare
Insurance through work
Other
Social and Emotional Health
We ask these questions to see if there are other resource recommendations we can make for you while you are at the clinic.
How often does the patient see or talk to people that they care about and feel close to?
Less than once a week
1 or 2 times a week
3 to 5 times a week
More than 5 times a week
Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. Does this describe the patient?
Not at all
A little bit
Somewhat
Quite a bit
Very much
If the patient had not come to Clinic with a Heart to get care, how likely is it that the patient would have gone to the emergency room to get care?
Extremely likely
Likely
Unlikely
Extremely Unlikely
Does the patient feel physically and emotionally safe where they currently live?
*
Yes
No
Family and Home
Including yourself, how many people live in your household?
*
What is your housing situation today?
*
I have housing
I do not have housing -- I am staying with others
I do not have housing -- I am staying in a hotel
I do not have housing -- I am living in a shelter
I do not have housing -- I am living outside or in my car
Are you worried about losing housing?
*
No
Yes
What is the highest level of school you have finished?
Less than a high school diploma
High school diploma/GED
Some college
College degree
What is your current work situation?
Unemployed and seeking work
Unemployed and not seeking work (retired, disabled, etc)
Employed full-time
Employed part-time
What is your family's combined yearly household income?
No income
Less than $15,000/year
$15,001 - $30,000/year
$30,001 - $45,000/year
More than $45,000/year
Have you been in jail or prison in the last 30 days?
No
Yes
In the past year, have you or any family members you live with, been unable to get any of the following when it was really needed? (Check all that apply.)
Food
Clothing
Utilities
Child Care
Phone
Medicine or Healthcare
Transportation
None
Other
If you are 45+, Are you interested in a Colon Cancer Screening Test kit
Yes
No
How did you hear about Clinic with a Heart?
Health History
Where do you usually go for your medical care?
*
Do you have a regular doctor?
*
No
Yes
Do you have a regular dentist?
No
Yes
Who is your regular doctor?
Who is your regular dentist?
Why did you come to Clinic with a Heart, rather than going to your regular doctor?
Are you currently in a treatment center/program?
No
Yes
Is your visit today due to a work-related illness, injury, or accident?
*
No
Yes
Who was your employer at the time of the injury?
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What was your job title at the time you were injured?
On what date did the injury occur?
-
Month
-
Day
Year
Date
At approximately what time did the injury occur?
Hour Minutes
AM
PM
AM/PM Option
What type of work was being performed at the time of injury?
Describe the accident or injury.
Was the accident directly related to your work?
No
Yes
Was anyone else present during your accident?
No
Yes
Did you report your accident to your employer?
No
Yes
What recommendations did your employer make just after the accident?
Have you been able to work since the injury?
No
Yes
Are your work activities restricted as a result of this injury (if so, we ask additional questions so you have a good record of the incident in case you should need it)?
No
Yes
Have you retained an attorney?
No
Yes
Is your visit today due to a motor vehicle accident?
*
No
Yes
Do you currently use any of the following nicotine or tobacco products? Please select one or more.
*
Chewing Tobacco
Cigars
Cigarettes
Tobacco Pipes
Nicotine Replacement Gum or Patches
E-Cigarettes
Vaping Products
None of the above
How often do you use any of the above chosen products
Less than 10 times a day
11-20 times a day
21-30 times a day
How often do you drink alcohol?
*
Never
Sometimes
Daily
How often do you use street drugs including Marijuana?
*
Never
Sometimes
Daily
Excluding pregnancies, have you been to the emergency room or been hospitalized in the past 24 months?
Year
What was the illness or operation
Reason 1
Reason 2
Reason 3
Reason 4
Regarding your dental visit:
*
No
Yes
Are your teeth sensitive to cold, hot, sweets, or pressure?
Do you have swelling?
Do you have throbbing pain?
Have you been prescribed antibiotics for your dental concern?
Have you been to the ER regarding your dental concern?
Have you ever had an unfavorable experience during a dental visit?
How long have you been experiencing your dental issue?
What have you done to relieve your dental pain?
Are you currently pregnant?
*
No
Yes
Don't Know
Are you using birth control?
*
Yes
No
Approximate date of last menstrual cycle.
*
Health History
In the past have you had any of the following?
Allergic/ Immunologic/ Hematologic/ Endocrine
*
No
Yes
Allergies/Hayfever
Anemia/Bruise easily
Cancer
Diabetes
Thyroid disease
Notes:
Cardiovascular
*
No
Yes
Pacemaker or an internal defibrillator
Chest pain
Heart disease
Heart murmur
High blood pressure
High cholesterol
Stroke
Notes:
Gastrointestinal
*
No
Yes
Abdominal pain
Bowel problems
Eating disorder
Gall bladder trouble
Hepatitis
Jaundice
Ulcers
Notes:
General/Constitutional
*
No
Yes
Fatigue
Loss of appetite
Recent weight loss
Recurrent infections
Skin rashes
Vomiting
Fever
Notes:
Genitourinary
*
No
Yes
AIDS/HIV
Kidney problems
Prostate disease
Sexually transmitted infections (STI)
Urination problems
Notes:
Eyes, Ears, Nose, Mouth, Throat
*
No
Yes
Blindness
Blurred vision
Eye pain
Glaucoma
Hearing loss
Macular degeneration
Notes:
Neurologic/ Psychiatric
*
No
Yes
Depression or mental illness
Anxiety
Fainting
Headaches/Migraines
Numbness/Tingling sensations
Seizure disorder
Tremors/Hands shaking
Dizziness
Notes:
Orthopedic
*
No
Yes
Arthritis
Back pain
Bone fracture
Muscle or joint pain
Osteoporosis
Notes:
Respiratory
*
No
Yes
Asthma/Wheezing
Bronchitis
Chronic cough > 3 weeks
Shortness of breath
Tuberculosis/Exposure
Notes:
Do you have any other health concerns not listed?
Name of person registering the patient (staff or volunteer)
First Name
Last Name
Submit
Veteran's Resources (grey)
Healthcare Resources (bright pink)
Mental Health Resources (yellow)
Housing Resources (light purple)
Rent/Utilities (bright orange)
Employment assistance (red)
Food (bright green)
Clothing (bright blue)
Child care (white)
Miscellaneous (light pink)
Phone (light pink)
Recently released from incarceration
Well Woman Resources (grey)
Work Injury
Do you feel safe (if there is a date next to this, please discretely contact staff)
Prostate screening referral
Should be Empty: