Sample New Patient Intake Form - Rainbow Welcome

1 Sample New Patient Intake FormAppendix B487 Date: _____Patient Intake FormWe d like to Welcome you as a new Patient . Please take the time to fill outthis form as accurately as possible so we can most appropriately addressyour health needs. The confidentiality of your health information is protected in accordancewith federal protections for the privacy of health information under theHealth Insurance Portability and Accountability Act (HIPAA).You will notice that we ask questions about race and ethnic do this so we can review the treatment that all patients receive andmake sure everyone gets the highest quality of this clinic recognizes a number of sexes/genders, many insurancecompanies and legal entities do not. Please understand that the legal nameand sex listed on your insurance must be used on documents pertaining toinsurance and billing.

2 If your preferred name and pronouns are differentfrom these, please let us print all : _____Date of Birth: _____Address: _____Sex/Gender: M F Intersex Transgendered _____Race (eg, African-American, Latino, Asian, etc)_____Home Tel (___) ___ - ____Ethnicity (eg, Mexican, Hawaiian, Irish, etc)OK to leave a message? Y N _____Work Tel (___) ___ - ____ Education Level: _____OK to leave a message? Y NCell Tel (___) ___ - ____ Occupation: (Do you work outside the home?OK to leave a message? Y N Please be specific in describing your work)_____1 Email Address:Number of Hours Worked per Week: _____OK to contact by email: Y N Religious/Spiritual Beliefs: _____Insurance Type: _____ Relationship/Marital Status: (eg, single, married,partnered, living together, divorced)ID#: _____ _____Subscriber: _____ Name of Your Partner or Spouse: (if applicable)Secondary Insurance: _____ _____ID#: _____ Do You Live with Anyone?

3 Y NSubscriber: _____ _____Language Spoken Most Often: Number of Children: _____ Ages _____At Home: _____At Work: _____ Do You Feel Safe at Home?: Y N SometimesDo You Need an Interpreter? Have you felt threatened, controlled by, or Y Nafraid of a partner, family member, or caregiver?YN488 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health2 Medical HistoryPlease check all that apply___ Emphysema___ Tuberculosis___ Pneumonia___ Bronchitis___ Asthma___ Allergies___ Heart Disease___ Stroke___ High Blood Pressure___ Elevated Cholesterol___ Diabetes___ Venous Thrombosis___ Hepatitis A___ Hepatitis B___ Hepatitis C___ Cirrhosis___ Anemia___ Thyroid Trouble___ Gallbladder Disease___ Ulcers___ Frequent Urinary Tract Infections___ Sexually Transmitted Infections___ Prostate Trouble___ Cancer___ Arthritis___ Osteoporosis___ Fractures___ Migraines___ Depression___ Anxiety or Panic Disorder___ Posttraumatic Stress Disorder___ Alcohol or Substance Use ProblemOther: _____Appendix B: Sample New Patient Intake Form4893 Systems ReviewPlease check any of the following symptoms that you have recently experi-enced or are a concern to.

4 ___recent weight loss___recent weight gain___fatigue___fever___changes in appetite ___night sweatsSkin:___rashes___lumps___itching__ _dryness___color change___hair or nail changeHead:___headaches___head injuries___dizzinessEyes: Date of last exam: ___/___/_____glasses___contacts___pain__ _double vision___redness___glaucoma___cataractsN ose:___frequent colds___nasal stuffiness___hay fever___nosebleeds___sinus trouble___dust/animal allergiesEars:___hearing lossMouth & Throat: Date of last dental exam: ___/___/_____bleeding gums___frequent sore throats ___hoarsenessNeck:___goiter___lumps/swol len glands___painBreasts: Date of last mammogram: ___/___/_____lumps___pain___nipple discharge4490 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender HealthRespiratory:___cough___wheezing___ shortness of breath___coughing up bloodCardiac:___heart murmur___chest pain___palpitations___swelling of feet___shortness of breathGastrointestinal:___trouble swallowing ___heartburn or gas___nausea___vomiting___rectal bleeding___constipation___diarrhea___abd ominal pain___hemorrhoids___jaundice (skin or whites of eyes turning yellow)Urinary:___frequent urination___painful urination___blood in urine___stones___difficulty urinating or difficulty holding urination___waking up to go to the bathroom several times at nightMusculoskeletal:___joint stiffness___arthritis___gout___backache_ __muscle pains___muscle crampsPeripheral Vascular:___leg cramps while walking___varicose veins___thrombophlebitisNeurological:___ fainting___blackouts___seizures___weakne ss___numbness___tremors___tingling hands or feet ___change in memoryPsychiatric/Psychological.

5 ___anxiety___depression___phobias___fami ly problems___eating disorderAppendix B: Sample New Patient Intake Form49156 Have you ever been hit, slapped, kicked, or otherwise physically hurt bysomeone?___Yes, in the past year ___Yes, prior to this past year___NoHas anyone ever forced you into having any type of sexual activity?___Yes ___NoHematologic:___anemia___easy bruising or bleeding___blood transfusions: Year(s) _____Endocrine:___heat or cold intolerance___excessive sweating___excessive hunger___excessive urinatingDo you experience chronic pain? Yes NoIf YES, how is your pain managed (ie, physical therapy, medication, etc)?_____On a scale of zero to ten, with ten being the worst and zero being nopain, how would you rate your current pain? ____Operations and/or Hospitalizations: (Please list surgeries and/or hospital-ization reasons and dates)_____Current Medications: (Please include any non-prescription drugs as well,eg, vitamins, aspirin, etc.)

6 Medication NameDoseFrequency of Use1. _____ _____ _____2. _____ _____ _____3. _____ _____ _____If you need more room, please list additional medications on back of last : (Please list any allergies you may have to medications and food)_____492 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health7 Family Medical HistoryPlease check all that Stroke___ Heart Disease___ High Blood Pressure___ Thyroid Disease___ Kidney Disease___ Diabetes___ Arthritis___ Osteoporosis___ Migraine Headaches___ Alcoholism___ Asthma___ Depression___ Anxiety___ Cancer/Type(s): _____Vaccinations/PreventionDate of Last Tetanus Vaccination: ___/___/ _____Have you received any of the following vaccines:Hepatitis A?Yes No Not SureHepatitis B?Yes No Not SurePneumo vax?Yes No Not SureHave you had a blood test for Rubella (German Measles)?Yes No Not SureDate of Last Colonoscopy: ___/___/____ ___ Check here if not applicableHow often do you wear seatbelts?

7 _____Are there any firearms kept in your home? Yes NoDoes someone have power of attorney or healthcare proxy giving them thepower to make decisions about your care in life-threatening situations?NoYes: (name of person and their relationship to you)_____Do you have an advanced health directive, such as do not resuscitate?YesNoAppendix B: Sample New Patient Intake Form4938 Gender IdentityPlease list any questions, concerns, or comments you have, if any, aboutyour gender or gender identity (sense of your femaleness/maleness)._____Sexual Orientation & Sexual HistoryHow do you identify in terms of sexual orientation?_____Are you attracted to (check all that apply):___Men ___Women ___Transgendered Men ___Transgendered WomenHave you had sex with (check all that apply):___Men ___Women ___Transgendered Men ___Transgendered WomenWhen you have sex, do you have (check all that apply):___Oral Sex___Vaginal Sex ___Anal SexHow often do you use condoms when having:Oral Sex: _____Vaginal Sex: _____Anal Sex: _____When is the last time you had sex without using a condom?

8 _____Do you have a primary (main) sexual partner?YesNoDo you have any casual sexual partners?YesNoWhen was the last time you were tested for HIV?_____What were the results? _____494 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health9 Please check any of the following infections that you have had:___Syphilis___Gonorrhea___Pelvic Inflammatory Disease___Herpes___Trichomonas___Genital Warts___ Yeast Infections___Chlamydia___Crabs___ Bacterial VaginosisFor each of the above that you checked, please note: 1) when the infec-tion was, 2) if you completed treatment, 3) if your partner(s) wereinformed, and 4) if you need help telling your ) _____2) _____ 3) _____ 4) _____1) _____2) _____ 3) _____ 4) _____1) _____2) _____ 3) _____ 4) _____1) _____2) _____ 3) _____ 4) _____Do you know or believe that any of your partners have had HIV oranother sexually transmitted infection?

9 YesNoI m not sureHave your current partners been tested for HIV and other sexually trans-mitted infections?YesNoI m not sureWhat were the results? _____Are you satisfied with your sexual life?YesNoI m not surePlease describe any sexual concerns you may have:_____Appendix B: Sample New Patient Intake Form49510 Gynecologic HistoryIf not applicable due to sex and/or gender please check here ___ and skipto Hormones sectionAge of First Period: ___Date of Last Pap: ___/___/___Results: ___Normal___AbnormalHave you everhad:An abnormal Pap?YesNoOvarian Cysts? YesNoFibroids?YesNoDES Exposure? YesNoHave you had a hysterectomy?YesNoIf YES: Why was it performed?_____Were your ovaries removed?Yes, bothYes, oneNoIf menopausal/postmenopausal, please check here ___ and skip to belowthe dotted lineDate of Last Period: ___/___/___Frequency of Periods: (eg, every 28 days) _____Average Length of Period: ___daysBleeding: ___Light___Moderate___HeavyOther Bleeding: ___No ___Yes, between periods ___Yes, after penetra-tive sexual activityDo you experience any of the following symptoms with your period?

10 Check all that ___Weight Gain ___Swelling ___Cramps ___Anxiety___Depression Other: _____Are you currently using birth control?YesNoIf YES: Which type are you using:___Pills ___IUD ___Condoms ___Foam ___Foam & Condoms___Patch ___Diaphragm ___Ring ___Depo ___Tubal Ligation ___Vasectomy Other: _____496 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health11 Have you evertaken birth control pills?Yes, for _____(how long?) NoAre you currently pregnant or planning to become pregnant?YesNoIf you have not begun menopause, please check here ___ and continue tothe next sectionAge at menopause: ___Have you evertaken estrogen replacement?YesNoIf YES: What was the name of the estrogen replacement?_____Age when estrogen replacement was started: _____How long was estrogen replacement used? _____What was your estrogen dose? _____Have you evertaken progesterone?