Health History Questionnaire

Name ____________________________________________________ Sex ________ Age ___________ Date ________________

PAST MEDICAL / SURGICAL HISTORY List any medical problem, major illness, or surgery; also, when you had it, or when it was first diagnosed none

HTN; DM; MI/CAD; CVA; CHF; COPD; CRI; PUD; HEP; OA; PVD; Cancer: Colon, Breast, Prostate; Hyster; Append; Cholecyst; CABG; BTL; C/S

List any medicine you take, or should be taking none

List any medicine you are allergic to, & what happens when you take it none

FAMILY HISTORY List any medical problems of your family, and age of diagnosis (HTN; DM; MI; cancer: colon, breast, prostate) none

mother

father

sister

brother

SOCIAL HISTORY

CIGARETTESDo you smoke, or ever smoked? Y N How many packs in a day? ________ How many years? ________ If quit, how long ago? ________

ALCOHOLHow many drinks do you have per day in an average week? ___________ Has anyone ever had concerns about the amount you drink? YN

SEX How old were you the first time you had sex? _______________ How many partners have you had altogether? _________________

PREGNANCIES total ________; full term ________, premature ________, miscarriages / abortions ________, living children ________

Christ CommunityH E A L T H S E R V I C E S

Reviewing Provider ______________________________________________ Form 4024-02

PATIENT REGISTRATION FORM

PATIENT INFORMATION Name (Last) (First) (Middle) (Jr, Sr, etc.)

Date of Birth / /

Gender Male Female

Social Security Number Marital Status Single Married Divorced Separated

Home Phone Number

( ) Work Phone Number

( ) Ext. Cell Phone Number

( )

Email Address

Full Address (Street or P.O. Box) Apt.#:

(City) (State) (Zip)

Who is your provider at CCHS?

Employment Status Full-Time Part-Time Full-Time Student Part-Time Student Retired Active Duty Unemployed

Please be prepared to present your insurance card, photo identification and proof of income documentation, if necessary.

RESPONSIBLE PARTY (Complete if different from above)

Relation to Responsible Party: Self Spouse Child Grandchild Foster Child Guardian Mother Father Other_______________________________

Name of Responsible Party (Last) (First) (Middle) (Jr, Sr, etc.)

Date of Birth / /

Gender Male Female

Social Security Number Marital Status Single Married Divorced Separated

Home Phone Number

( ) Work Phone Number

( ) Ext. Cell Phone Number

( )

Email Address

Full Address (Street or P.O. Box) Apt.#:

(City) (State) (Zip)

INSURANCE INFORMATION (If uninsured, please be prepared to present proof of income to qualify for discount program.) Primary Insurance (Carrier Name) Insurance Address Phone Number

( ) Policy Holder ID (Subscriber ID) Group # Subscriber Name Relation to Subscriber: Self Spouse

Child Other__________________ Co-Pay ($)

Secondary Insurance (Carrier Name) Insurance Address Phone Number ( )

Policy Holder ID (Subscriber ID) Group # Subscriber Name Relation to Subscriber: Self Spouse Child Other__________________

Co-Pay ($)

If you have more than two insurances, please provide the additional information at the time of registration.

ADDITIONAL REQUIRED INFORMATION What is your primary language? English Spanish Other_______________________

Do you require translation? Yes No

Are you Homeless? Yes No

If Homeless, what is your Living Situation? Shelter Transitional Staying with Family or Friends (Doubling Up) Street Other___________________

Are you a Veteran? Yes No

What is your race? Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than one race Other

What is your Ethnicity? Hispanic/Latino Not Hispanic/Latino

Are you an Agricultural Worker? Yes No If Yes, which are you: Migrant Seasonal

How did you hear about CCHS? Friend/Family Health Fair Other________________________________

How many any individuals reside in your household? How often are you paid? Weekly Bi-weekly Monthly Annually

What is your gross income (before taxes) during this time period? $_______________________________

Emergency Contact (Name, Address, Phone Number) Relation to Patient

Primary Pharmacy (Name) (Address) (Phone) (Fax)

AUTHORIZATION AND ASSIGNMENT

I do hereby voluntarily consent to medical care at Christ Community Health Services (CCHS). I hereby authorize all physicians and their assistants including Physician Assistants and Nurse Practitioners employed by CCHS to use such diagnostic and treatment procedures they deem necessary for proper medical management and treatment. I understand that Physician Assistants and Nurse Practitioners are not licensed physicians and may help provide medical care only under the supervision and direction of a licensed physician. I also assign the claim payments to be made payable to CCHS. I agree to the release of information to Medicare, TennCare and third party payors. I understand that some of the services that may be ordered may not be covered under Medicare, TennCare and other insurance and that I am responsible for any amount that is not paid. THIS AUTHORIZATION AND ASSIGNMENT IS A PERMANENT ONE-TIME SIGNATURE WHICH WILL REMAIN ON FILE AND WILL BE USED FOR FUTURE CLAIMS. I MAY REVOKE IT AT ANY TIME BY WRITTEN NOTICE. Signature of Patient/Responsible Party: __________________________________________________ Date: ___________________________

4028-03 Revised 01/03/2011

Form 4027-00

ADVANCE MEDICAL DIRECTIVEAND STATEMENT OF PATIENT RIGHTS

ACKNOWLEDGMENT FORM

PLEASE READ THE FOLLOWING STATEMENTS AND PLACE YOUR INITIALS IN THE BOXES.

INITIALS

I have been asked if I have an Advance Medical Directive(either a Living Will or a Durable Power of Attorney for Healthcare).

I understand I am not required to have a Living Will orDurable Power of Attorney for Healthcare in order toreceive medical treatments at this healthcare facility.

I understand this clinic will follow my written wishesin the event that I cannot speak for myself.

PLEASE CHECK THE BOXES THAT FIT YOUR STATUS

I have put in writing a: □ Living Will □ Durable Power of Attorney for Healthcare

□ I do not have any form of Advance Medical Directive.

□ Patient is unable to sign.

Registration Clerk Date

Signed Date

Signed Date

Form 4027-00

ADVANCE MEDICAL DIRECTIVEAND STATEMENT OF PATIENT RIGHTS

ACKNOWLEDGMENT FORM

PLEASE READ THE FOLLOWING STATEMENTS AND PLACE YOUR INITIALS IN THE BOXES.

INITIALS

I have been asked if I have an Advance Medical Directive(either a Living Will or a Durable Power of Attorney for Healthcare).

I understand I am not required to have a Living Will orDurable Power of Attorney for Healthcare in order toreceive medical treatments at this healthcare facility.

I understand this clinic will follow my written wishesin the event that I cannot speak for myself.

PLEASE CHECK THE BOXES THAT FIT YOUR STATUS

I have put in writing a: □ Living Will □ Durable Power of Attorney for Healthcare

□ I do not have any form of Advance Medical Directive.

□ Patient is unable to sign.

Registration Clerk Date

Signed Date

Signed Date