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New Patient Information Form

Please check all services that you are requesting:



     
 
    

Insurance Information (Please present ALL Insurance Cards and Picture ID)

 
 
 
 
 
 
 

Information for Statistical Reporting Only




If yes, please specify who and their relation to you and provide a copy of document to CHWP.

 

 

What are your top 3 goals for your first appointment?

 


Because we are partially funded by a federal grant, we are asked to collect income information. Please determine the number of persons in your household and check your annual (yearly) income range. This information is for generalized reporting regarding the health center. NO PERSONAL INFORMATION IS SHARED, but we may recommend completing our sliding fee scale application based on your response.

 
 

 


Health History

 
 

Past Medical History

Please check any condition you have been diagnosed with by a medical professional/provider.

Osteoarthritis of
Hypercholesterol ADHD
Asthma Hypertension Bipolar Disorder
Birth defects Thyroid:         Borderline Personality
Bleeding disorder:(type if known)
Gestational diabetes Schizophrenia
Cancer of
Kidney Disease Other:
COPD Liver disorder
Dementia:(type if known)
Migraine
Diabetes:     Stroke
Tuberculosis
 

Medications

Please list all medications, vitamins, supplements that you are currently taking. Please bring medications.

Medication name Dosage (mg) How often per day

Allergies

Please list medication, food, health related allergies and reactions. If reaction not known, enter "unknown".

Allergen:
Reaction:
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Hospitializations

Date: Location: Reason for stay: Length of stay:
 
 
 
 
 
 
 
 
 
 
 
 


Surgical History

  Date:   Type of Surgery:   Hospital/location:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Family History
 

  Condition Mom Dad Dad's Dad Dad's Mom Mom's Mom Mom's Dad Sibling Child
  Alcoholism                
  Dementia                
  Anemia                
  Asthma                
  Birth Defects                
  Bleeding Disorder                
  Cancer
(indicate type)
 
 
 
 
 
 
 
 
  Diabetes                
  Heart Disease                
  High Colesterol                
  Stroke                
  Heart Attack                
  Migraine                
  Epilepsy                
  Glaucoma                
  Thyroid Issues                
  Suicide                
  Tuberculosis                







Social History

Have you been sexually active in the last 12 months? 
Men, women, or both: 
Have you ever had a sexually transmitted disease? Type:
Type of contraceptive/protection used:
 

 

Female History

  Date of Last Period: 
  Age at first period:
  Number of pregnancies: 
  Number of children: 
Any chance you are pregnant now? 
Complications during pregnancy?
Last PAP Smear
Where performed:
Last Mammogram
Where performed:
 

Signature of Patient (Parent/Guardian if under 18)

By typing my name below as my signature I consent to submit this information to Community Health & Wellness Partners. I may be contacted by an employee of CHWP to validate my identity. I am not required to sign this form in order to submit it, but will be asked to sign a paper copy of it prior to receiving services.