Adult Health History

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Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure High cholesterol Mental illness Alcoholism/addiction Heartattack Cancer Stomach Ulcer Migraine Ashma HIV/AIDS Diabetes Tuberculosis Emphysema/bronchitis Thyroid problems Hepatitis A/B/C Blood transfusions Other: Hospitalizations (not surgery): Surgeries: Serious injuries and automobile accidents: Occupation: Who do you live with: Family History: Answer for parents, brothers, sisters, grandparents: Unknown Alcoholism Heart Disease Asthma High blood pressure Diabetes Cancer Stroke Mental Illness Lung Disease Other Women s Health: Age at first period Date of last period Year of last Pap Result of Pap Year of last mamo Result Birth control used now Number of pregnancies Births Immunizations: All childhood shots Last tetanus Last Influenza Last Pneumonia Hepatitis A Hepatitis B Last skin test for TB Reaction to TB test: Pos Neg Tobacco Use: Cigarettes Yes No Year Started Year Stopped Avg amt Chew/snuff Yes No Year Started Year Stopped Avg amt Alcohol Use: Never Daily Weekly Monthly Less than Monthly Other Drugs: Never Daily Weekly Monthly Less than monthly Ever IV? No Yes Marijuana Methamphetamine (crank/speed) Cocaine Heroin Other Signature: Provider Signature:

Medication Worksheet Name: DOB: Medication Name Strength Frequency Reason for Taking Example: Lisinopril 1-mg Once a day High blood pressure

Annual Patient Update Packet You have a right to confidential services, if you feel you may be subject to emotional or physical harm, please mark yes and see additional form. NO YES Patient s Name: Middle: Last: Date of Birth: Age: Marital status: Sex: Male Female Patient s SSN: Cell: Home: Work: Email: Are you signed up with the Patient Portal: Responsible Party: Date of Birth: Mailing Address: City: Zip: Physical Address: Employed? Yes No Employer: Full time Part-time Seasonal/Temp Student? Yes No Status: Full time Part time Agricultural Work Status: migratory seasonal none Emergency contact: Phone: Insurance Coverage: OHP Medicaid Medicare Commercial Insurance None Primary Insurance: Policy Holder: Relation to patient: Date of birth ID# Group # Employer: Secondary Insurance: Policy Holder: Relation to patient: Date of birth ID# Group #: Employer: Please provide a list of all the parties we may speak with or leave a message with regarding the patient's medical care, including mental health issues, HIVIAIDS related records, appointment scheduling, or payment information. This is not a release for medical records. This is only for permission to speak with desigated family or personal representatives. Name: Relationship: Phone: Name: Relationship: Phone: Please write a date that you are giving the above-named people permission to discuss your medical information or initial on lifetime line. Authorization period: FROM: TO: OR LIFETIME: Patient Signature (legal guardian):

The following information is needed to assist the clinic in securing funds. Your cooperation is appreciated. All information disclosed in this section is reported anonymously and will not impact access to care. Please circle the correct amount or check the box if monthly income is above all amounts. Number of Persons in Household 1 2 3 4 5 6 Household Income is Less Than 1,005 1,353 1,702 2,050 2,398 2,747 Household Income is Less Than 1,337 1,800 2,263 2,727 3,190 3,653 Household Income is Less Than 2,010 2,707 3,403 4,100 4,797 5,493 Income is Above all amounts Choose not to provide my financial information. Have you ever been in the military? Yes No Have you been seen at the VA? Yes No US citizenship: By Birth Permanent Resident/Alien Student Visa Other Ethnicity: Hispanic Non-Hispanic Choose not to disclose Race: Black White Asian American Indian Pacific Islander Hawaiian Other Language Spoken: Do you need a translator? Yes No Are you: a single parent? Yes No Homeless? Yes No Resident of public housing? Yes No Gender Identity: Male Female Transgender Male Transgender Female Other Choose not to disclose Sexual Orientation: Straight Lesbian/gay Bisexual Other Don t know Choose not to disclose The undersigned patient or individual acting on the behalf of the patient agrees as follows: 1. Authority is granted to Umpqua Community Health Center, to render needed treatment to the above named patient. 2. I authorize Umpqua Community Health Center to release needed treatment to the above named patient. 3. I authorize payment of medical benefits to Umpqua Community Health Center for services rendered. 4. I understand that I am responsible for all charges incurred through Umpqua Community Health Center. I request that payment under the medical Insurance program be made to the provider named above on any bills for services furnished to me during the effective period of this authorization and I authorize the above named provider to release to the Social Security Administration any information needed for this claim or any related Medicare claim. I further permit a copy of this authorization to be used in place of the original. If it becomes necessary to effect collection of my account the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees and court costs. Signature of applicant: Signature Parent/Guardian Staff initials/

Receipt of Notice of Privacy Practices Written Acknowledgement I, have received a copy of Umpqua Community Health Center s notice of Privacy Practices. (Signature of patient or legal guardian) (Printed patient or legal guardian) For Internal Purposes Only: We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: -Individual refused to sign. -Communication barriers prohibited obtaining acknowledgement. -An emergency situation prevents us from obtaining acknowledgement. -Other (please specify): Page 5 of 6 Rev. date: 07.03.2017 Required Rev. date: as needed Dept. Medical c:\users\ddebernardi\downloads\2018 new patient forms.docx

Office Policies MAKING APPOINTMENTS: Please be as specific as possible regarding your area of concern. This will help us to schedule the proper amount of time necessary for your care. MISSING APPOINTMENTS: Please notify the Clinic as soon as possible if you are unable to keep your appointment. Canceling appointments less than 24 hours in advance could result in a no show. This also includes referral appointments to outside clinics, physicians, and walking out on your appointment. Our answering service is available 7 days a week, 24 hours a day for your convenience. Please notify us if your scheduled appointment time needs to be changed. This allows for someone else who is waiting to be seen. BEING LATE FOR APPOINTMENTS: Please be at least 10 minutes early for your routine appointments and 30 minutes early for new patient appointments. This will ensure staff has time to input your information into your chart. Your appointment time is an allotted time. (Patient or responsible party initials) LAB AND X-RAY REPORTS: Your lab and x-ray results are part of the total picture of your health and must be analyzed by your health care provider in light of your history and physical exam. When you have a lab or x- ray there will be additional charges that you are responsible for. Please check with that office before you have the services. You will be notified of your results, or your provider will discuss your results at your follow-up visit. Please allow up to 2 weeks for this process. PRESCRIPTION REFLL POLICY: Please call your pharmacy and request a refill, even if it states no refill they will notify us. Please give us 48 to 72 hours to process your refill. We will review your chart and notify the pharmacy of the practitioner s decision. Please notify the pharmacy 1 week before your meds are finished. It is your responsibility to monitor the amount of medication you have. REFERRALS FOR OREGON HEALTH PLAN PATIENTS: The Oregon Health Plan requires us to submit a request for referral when the practitioner orders a specialist consult. The process can take up to 1 week or sometimes longer. We will contact you when this process has been completed and instruct you to call the specialist to make your appointment. Please be patient. It takes time to get the approval. PAYMENTS: Payments are expected at the time of service. You will be told what your minimum expected amount will be for each appointment. The amount could be more according to the procedures done. If you are unable to pay at the time of your visit your appointment may need to be rescheduled. (Patient or responsible party initials) I have read the above and agree to the terms provided. Signature:

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