A New Patient Letter and an Intake Packet

Welcome to Compassion Health Facility

Attached is patient’s Registration Package for Compassion Health Facility.  We request you to complete the intake form (registration package) to ensure that we maintain accurate contacts and medical records. If you access these forms online from our website, we require that you come with a printed copy during your appointment in the facility, as well as, other items listed at the end of this letter. We understand that you have a choice of where to seek your health care. We also understand that you value receiving the best patient-physician relationship where you will receive the best care, treatment options, and enjoy a shared decision way of care. It is our appreciation that you value to receive that form of care from our facility.

Compassion Health Facility specializes in diagnosis and treatment of general illnesses, including both communicable and non-communicable diseases, post and antenatal service, maternity services, emergency services, and other general services. We provide comprehensive care to our patients and their families by helping them attain the best of what is offered by the contemporary medicine. Our greatest commitment is quality patient care where we emphasize on individualized attention to each patient. We focus on provision of quality and efficient time to each patient. We attain this through the provision of best care services, in a confidential and comfortable environment to ensure total patient satisfaction.

Your privacy is protected by Health Insurance Portability and Accountability Act (HIPAA). Some of the aspects that Compassion Health Facility has adopted include maintenance of confidentiality in your information unless it is essential to the delivery of services or in ensuring appropriateness of your care. The HIPPA requires health professionals to remind patients’ of their appointments. Here at compassion we attain this through U.S. mail, email, telephone or any other means convenient to you. HIPPA provides patients with the rights to bring any complaints or concerns regarding privacy to the attention of the doctor or M.D. Through HIPAA, here at Compassion patients are able to access their records in accordance with the state and federal laws. The patients are then required to fill the HIPAA Statement below:

I, _____________________________________________ date __________________ do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

As a patient, you are required to fill the receipt of Privacy Notice. This is because you have entrusted your medical information to our facility and we understand our relationship with you is based on trust. We hereby hold ourselves responsible to safeguard your private information. For example, the Privacy Notice stipulates that a patients’ information should not be used for any marketing or fundraising. The patient will be required to fill the following:

I,____________________________________________________ (Patient’s name) hereby affirm that I have received a copy of the Notice of Privacy Practices from Compassion Health Facility. I am entitled to receive a copy from my health provider as stipulated by HIPPA, also known as under federal law 104-191. My signature in this form means I have received the notice but it is not an obligation in any way. I understand my entitlement to receive the Notice of Privacy Practice whether I sign or not. 

Patient’s Name_______________________________________________

Signature of Representative or Patient_____________________________

Date________________________________________________________

Representatives Relationship to Patient (if applicable)_________________

Our greatest value is a strong relationship with our patients; in particular, we value feedback from our patients. Hence, after the delivery of services we require feedback on your experiences regarding our services. Keep in mind that whatever feedback you provide matters. The feedback received will help us to better our services to you and other patients. In case of concerns or questions, feel free to contact any of our team members. 

Warmest regards

Tom Jones, M.D

ITEMS REQUIRED DURING YOUR VISITInsurance Card: For all patients with health insurance, we require a copy of your card to bill your insuranceDeductible or Co-pay: This will be collected during your check-in Written Referral: Please ensure that your previous health records are emailed or faxed to us by your primary care provider, or have a written referral from your primary care physician if required by your insurance plan.Diagnosis and treatment procedures will be due at your time of visitCompleted Patient Registration Package/Intake formsMinors must be accompanied by a parent or legal guardians

INTAKE FORM

Patient Information

PLEASE PRINT LEGIBLY

Name	Date of Birth:	Appointment Date/Time
Address:	City:	State, Zip:
Email:	Mobile Phone:	Home Phone:
Sex/Gender:	Marital Status:	Occupation

Employer’s Name

Race:    ☐ White ☐ African American/Black ☐ Native America

☐ Pacific American/Asian ☐ Hispanic/Latino ☐ Other _____________

Primary Language____________________ Do you require a translator?________

Do you have any of the listed allergens? If yes, specify

Latex Allergy:   Yes  ☐       No ☐ List Reaction_________________________

Drug Allergy:    Yes ☐       No ☐ List Allergen with reaction______________

Food Allergy:    Yes ☐     No ☐ List Allergen with reaction______________  

Did you arrive from:  ☐ Clinic  ☐ Emergency Department ☐Rehabilitation 

Home  ☐      ☐ Extended Care Facility ☐ Others (specify)________

Do you have any of the characteristics? ☐ Heart disease issues     

☐hospitalized in the last one year 

☐ Surgeries 

Do you have an advance directive? ☐ Yes ☐ No which one?

☐ Out of Hospital Do Not Resuscitate ☐Mental Health Directive 

☐Living Will ☐Power of Attorney

INCASE OF EMERGENCY 

Name of relative or friend	Relationship to patient	Mobile Number	Secondary No.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims Patient’s or Guardian’s Signature_____________________    Date_______________________

Past Medical History

Conditions	Have you ever experienced this?	Has a closeFamily member?	Please explain
Thyroid disease	☐ Yes     ☐ No	☐ Yes     ☐ No
Stroke	☐ Yes     ☐ No	☐ Yes     ☐ No
Seizures	☐ Yes     ☐ No	☐ Yes     ☐ No
Lung Disease	☐ Yes     ☐ No	☐ Yes     ☐ No
Lung Disease (e.g. asthma, etc.)	☐ Yes     ☐ No	☐ Yes     ☐ No
High Cholestrol	☐ Yes     ☐ No	☐ Yes     ☐ No
High Blood Pressure	☐ Yes     ☐ No	☐ Yes     ☐ No
Heart Disease	☐ Yes     ☐ No	☐ Yes     ☐ No
Digestive Disorders	☐ Yes     ☐ No	☐ Yes     ☐ No
Diabetes	☐ Yes     ☐ No	☐ Yes     ☐ No
depression	☐ Yes     ☐ No	☐ Yes     ☐ No
Cancer (type……..)	☐ Yes     ☐ No	☐ Yes     ☐ No
Hepatitis A, B, C	☐ Yes     ☐ No	☐ Yes     ☐ No
Dementia	☐ Yes     ☐ No	☐ Yes     ☐ No
High risk pregnancy	☐ Yes     ☐ No	☐ Yes     ☐ No
Cerebral palsy	☐ Yes     ☐ No	☐ Yes     ☐ No
Dental cavities	☐ Yes     ☐ No	☐ Yes     ☐ No
Meningitis	☐ Yes     ☐ No	☐ Yes     ☐ No
Nose bleeds	☐ Yes     ☐ No	☐ Yes     ☐ No
Head Injury	☐ Yes     ☐ No	☐ Yes     ☐ No
HIV/AIDS	☐ Yes     ☐ No	☐ Yes     ☐ No
Congestive Heart Failure	☐ Yes     ☐ No	☐ Yes     ☐ No
Cataract	☐ Yes     ☐ No	☐ Yes     ☐ No
Blood Disorder	☐ Yes     ☐ No	☐ Yes     ☐ No
Amputation	☐ Yes     ☐ No	☐ Yes     ☐ No
Anemia	☐ Yes     ☐ No	☐ Yes     ☐ No
Other	☐ Yes     ☐ No	☐ Yes     ☐ No
Other	☐ Yes     ☐ No	☐ Yes     ☐ No
Other	☐ Yes     ☐ No	☐ Yes     ☐ No
Other	☐ Yes     ☐ No	☐ Yes     ☐ No

Provide a list of medications you are currently taking:

1.  
2.  
3.  

Please list any medications you are allergic to

Medication	Intolerance/reaction
a)
b)
c)

Have you been exposed to any harmful environmental substances?

For Women Only

Are you: ☐ Not Applicable ☐ Menopausal ☐Pregnant

   ☐ Menstruating  ☐ Unknown 

Date of your last menstrual period: _/ _/ _

Are you lactating or breastfeeding?   ☐ Yes ☐ No

Number of times you have been pregnant: _____ Number of children: _____ Abortion: _____

Have you had a mastectomy (tick)        ☐ Yes ☐  No

Have you had a hysterectomy?              ☐ Yes ☐ No

Social history (please tick all that apply)

Alcohol Use	Tobacco Smoking
3 or more drinks per day	Former Smoker
1-2 drinks per day	Has smoked in the past (socially)
Less than 1 drink per day	Currently Smokes
NONE	Never Smoked

Vaccines

When is the last date you took each of the following vaccines?

☐ Tetanus  ☐ Pneumococcal vaccine ☐ Flu, N1H1 ☐ Flu 

☐ Hepatitis 

If you have diabetes, answer where appropriate 

Which type of diabetes  ☐ Type 1 ☐ Type 2

Onset Date: ☐ More than five years ☐ 1-5 years ☐  New onset 

Do you effectively monitor your blood sugar at home? ☐ Yes ☐ No

Do you administer insulin properly? ☐ Yes  ☐ No

Do you follow and exercise plan?     ☐  Yes ☐ No

Do you follow a meal plan?              ☐ Yes ☐ No

Do you know how to manage your diabetes during emergencies? ☐ Yes ☐No

Do you know how to administer oral hypoglycemic medications?  ☐ Yes ☐ No

Do you know the symptoms of low blood sugar? ☐ Yes ☐ No

Functional Screening

In the last 1 month, have you had reduced functions in the following areas:

No changes in activities of daily living in the last one month

☐ Communication ☐ Swallowing ☐ Self-feeding ☐ Dressing 

☐ Bathing ☐ Toileting ☐ Transferring ☐ Walking

☐ Others (specify)

Have you used any assistive tools while at home? ☐ Yes ☐ No

If yes, please specify:  ☐ Walker ☐ Prosthesis     ☐ Crutches ☐ CPAP

☐ Commode       ☐ Cane ☐ Oxygen   ☐   others (specify )

Living Environment Screening 

Do you live alone?  ☐ Yes ☐ No

If no, with whom? ☐ Spouse ☐ Parents   ☐ Grandparents   ☐ Friend

☐ Children ☐ Significant Other     ☐ Others (specify)

Do you care for another person?  ☐ Yes ☐ No

If yes, who? ☐ Spouse ☐ significant Other ☐ Pet ☐ parent 

☐ Friend ☐ Children 

What are your anticipated changes due to your condition?

☐ Inability to work ☐ Inability to care for someone else

☐ Inability to care for self ☐ None  ☐ Others specify 

What is your living condition? ☐ None Permanent Address ☐ Homeless

☐ House ☐ Foster Care ☐ Extended Care Facility ☐ Assisted Living

☐ Apartment

Do you currently use a home care agency?       ☐ No ☐ Yes If yes please specify ______

______________________________________________________________________________

Do you have resources to obtain your medication?  ☐ No  ☐ Yes 

 Nutrition Screening 

1. How would you describe your relationship with food?

2. Are you currently under any special diet? If yes, which one

3. Any group of food that you dislike or do not eat?

4. On a typical day, what do you drink?

5. Which type of food do you crave for?

6. Do you consider yourself, a healthy eater? If yes, why?

Other Information

1. What are your goals for healthcare services at Compassion Health service?

2. What do you like most about yourself?

3. What are some of your strengths? 

4. Do you have any other aspects you would require us to discuss?

Completed by ____________________________________ Date ________________________

If not Patient, what is your relationship to the patient? _________________________________