Date of birth:

Patient Sex: oMale oFemale oUnknown

Preferred method of contact: oMail oPhone oE-mail oMyChart

Subscriber DOB:

Preferred language:

Cell Phone:Name:

Emergency Contact Information

Email Address:

Secondary Insurance (If applicable): Subscriber Name:

Home phone:Relationship:

Patient Information

Home Address:

Work Phone: ( )

Patient Name:

City, State, Zip:

Relationship status:oDivorced oLegally separated oMarried oSignificant other

oSingle oUnknown oWidowed oOther

Cell phone number: ( )

Home phone: ( )

SSN:

If under age 18- Parent(s)/Guardian(s) name(s):

Preferred Name:

Subscriber Name:

Subscriber DOB: Subscriber Sex: oMale

oFemale oUnknown

Insurance Information

Primary Insurance:

Patient Relationship to subscriber:

Patient Relationship to subscriber:

Additional Information

Subscriber Sex: oMale

oFemale oUnknown

Answer the following questions about the patient being seen today:

Why do we ask this

information?

NOAH is a Federally Qualified Health Center (FQHC); we are asked to track and

report data on our patients. All information is kept private. Thank you for

completing all of the information on this form.

Approved & Revised 6/4/19

oYes oNo

Ethnicity:

How did you hear

about us?

Sexual Orientation:

Estimated Income:

NO SHOW POLICY

DatePatient/Guardian Signature

Are you a Farm Worker?

oMonthly o Annually

oHispanic or Latino oNot Hispanic or Latino

It is important for you to keep all of your appointments. Please contact us as soon as possible if you

cannot make it to your appointment. We ask for at least a 24-hour notice if you are going to cancel or

change your appointment. Three (3) missed appointments within six (6) months will result in a same-

day only appointment status. Continued no-shows may result in dismissal from NOAH.

By signing below, I state that the information on this form is true and correct to the best of my

knowledge. I also have been informed and understand the NOAH No Show Policy.

Are you a Veteran?

oNOAH website oInsurance company oEvent oFamily or Friend

oPhysician referral oPostcard oSocial Media

oFlyer or brochure oOnline directory oHospital2NOAH program

Family Size (how many people are in your household):

Race:

oAmerican Indian/ Alaska Native oAsian oBlack/ African American

oCaucasian oNative Hawaiian oPacific Islander

oMore than one race oOther oRefused

Are you Homeless?

oMigrant Farm Worker oNot a Migrant Farm Worker

oSeasonal Farm Worker oPatient Refused

o Yes o No

Gender Identity:oMale oTransgender Female(Male to Female) oOther

oFemale oTransgender Male (Female to Male) oChoose not to disclose

oStraight (not lesbian or gay) oBisexual oDon't know

oLesbian/gay oChoose not to disclose oSomething else

Approved & Revised 6/4/19

Full Legal Name: Date of Birth:

Preferred Name:

Allergies:

Pharmacy Name & Cross Streets: Phone:

Name of Medication Dose How often do you take

it? What is this medication for?

ADD/ADHD Cancer GERD/ Acid Reflux Migraines

Allergic Rhinitis Cataracts Glaucoma Heart Attack (MI)

Anemia Heart Failure (CHF) Heart Murmur Stomach Ulcers

Anxiety COPD HIV/AIDS Seizures

Asthma Coronary Artery Disease Hyperlipidemia Sexually Transmitted Disease (STD)

Arthritis Depression Hypertension Stroke

Bipolar Disorder Diabetes Mellitus Type 1 Hyperthyroidism Substance/Drug Abuse

Blood Clots Diabetes Mellitus Type 2 Hypothyroidism Valley Fever

Blood Transfusion Emphysema Kidney Disease Other:

Please mark any appropriate medical conditions/problems that you have been treated for:

Health History Form

Medication: Please list any medications, vitamins or over the counter medicine you are currently taking.

Your Birth History (If known):

Delivery Method: Gestational Age: Full Term Pre-mature

Birth Length: Birth Weight: Birth Head Circumference:

Do you

currently

use

Alcohol?

Yes

Not currently

Never

How

much do

you drink

per

week?

_____ Glasses of Wine

_____ Cans of beer

_____ Shots of liquor

_____ Mixed drinks

How often do

you have 6+

drinks in a

day?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you ever smoked?

Yes

No

What is your current smoking

status?

Never Smoked

Current every day smoker

Current some day smoker

Former Smoker

What year did you start smoking?

__________

How many packs per day did/do you smoke?

__________

What year did you quit smoking?

__________

Type:

Cigarettes

Pipe

Cigars

Chew/Snuff

E-cig/Vape with nicotine

Appendix removal Colon surgery Eye surgery Joint replacement Tonsils removed

Breast Implants Heart stent Surgery for a

broken bone

Spine surgery Tubal Ligation

Heart Bypass (CABG) Cosmetic Surgery Hernia Repair Thyroid surgery Heart valve

replacement

Gallbladder removal

(Cholecystectomy)

C-Section Hysterectomy Other: Other:

Surgical History: Please mark any surgeries that you have had.

Family

History:

High Blood

Pressure

Cancer

(Type) Diabetes Migraines Stroke

Thyroid

Disease

COPD/

Emphysema

Heart

Disease Other

Mother

Father

Siblings

Children

Do you use recreational

drugs?

If yes, type:__________

Yes

No

Marital

Status:

Single

Married

Widowed

Legally separated

Divorced

Significant Other

Are you Sexually Active? Yes

Not currently

Never

With: Men

Women

Both

Do you use Birth Control/

protection/barrier?

Yes

No

Type of birth control/

protection/barrier used?

________________

Approved & Revised 06/04/2019

Patient/ Responsible Party Print Name:

Patient/Responsible Party Signature: Date: __

At times, we will call, text, or email you with appointment reminders or leave general informational messages on your voicemail.

I give permission to NOAH to communicate messages regarding appointments, referrals, lab results, and other information pertaining to my care.

May we leave a message on your home phone regarding the treatments you have received at NOAH:

Medical Dental Behavioral Health

(Please circle all that apply)

Home phone number:

May we leave a message on your cell phone regarding the treatments you have received at NOAH:

Medical Dental Behavioral Health

(Please circle all that apply)

Cell phone number:

May we mail results or documents to your home regarding the treatments you have received at NOAH:

Medical Dental Behavioral Health

(Please circle all that apply)

I give permission to NOAH to discuss my personal health information with the following individuals:

Name Relationship to Patient

Communication Consent Form

Patient Name: Date of Birth:

Approved & Reviewed 06/04/2019

Consent for Treatment without Parent or Guardian Present

Patient Name: DOB:

I authorize and give permission to the following individual(s) that are adults to accompany my child for

treatment and to make decisions for any necessary treatment. The person bringing the child in must

remain with the child while the child is being seen. This permission will remain in effect until revoked by

the parent of guardian.

Emergency contact number(s) for parent/guardian:

Parent/Guardian Name (Printed) Parent/Guardian Signature Date

Name of individual Relationship to child Phone number

Office Use Only

ID verified by:

Date:

ID of Authorized Individual

If Passport is used, scan a copy into the chart