New Patient Download New Patient Form or fill the form below Patient's Name / Nombre del paceinte* First Last Date of Birth / Fecha de naciemiento* MM slash DD slash YYYY Phone Number / Numero de telefonoIs there anyone in your immediate family who is a patient with our clinic? / Hay alguien en su familia immediata que sea paciente con nuestra clinica? Yes No Any medical problems acute or chronic / Cualquier problema de salud ayudo o chronico?Current medications including those you take as needed / Las medicamentos actuales incluyendo lo que usted toma por necesidad*IT IS IMPORTANT THAT YOU BE AWARE THAT OUR PROVIDERS DO NOT PROVIDE PAIN MANAGEMENT TO PATIENTS / ES IMPORTANTE QUE USTED ESTE ENTERADO QUE NUESTROS PROVEEDORES NO MANEJAN DOLOR CHRONICO EN LOS PACIENTES*Have you been seen in any clinic hospital, or Medi-Centers? If so, which one? / Ha sido visto en cuelquier clinica, hospital, centros medicos? Se ese es caso cual? Reason for transfer / Motivo dela transferenciaType of insurance / Tipo de aseguransa How did you hear about our clinic? / Como se entero de nuestra clinica? Preference of doctor / La preferencia del medico? Dr. Halma Dr. Bond Marivel Sandoval, PA-C Ramon Perez Jr, PA-C Maricela Ramirez, PA-C Margaret Kranz, PA-C Bristol Fletcher, ARNP I Certify* I Certify that this information is correct and true, if found to be incorrect or false this may affect your acceptance to our clinic / Certifico que esta informacion es correcta y verdadera, si encontramos ser inexact o falsa esto puede efectar aceptacion a nuestra clinicaAUTHORATION TO RELEASE HEALTHCARE INFORMATIONSocial Security # I HEREBY REQUEST AND AUTHORIZE THE FOLLOWING RELEASE OF INFORMATIONINFORMATION RELEASED TO: Swofford and Halma Clinic, Inc. 2303 Reith Way PO BOX 119 Sunnyside, WA 98944 Phone # 509-837-3933 Fax # 509-837-3885INFORMATION TO BE SENT FROMPurpose, must check all that apply* Possible Transfer of Care OB Care Others/Self Newborn-present 2016-Present The following records are requested for release: Must Initial all that apply* All Medical Records Progress Notes Lab & X-rays Prenatal History Pap Smear Ultrasound Immunization Record SIGNATURE OF PATIENT OR PATIENT'S AUTHORIZED REP.* First Last RELATIONSHIP SIGNATURE OF WITNESS First Last TITLE My initials and signature below authorize the release of healthcare information relating to testing, diagnosis, and treatment for: Must initial the following:* HIV/AIDS Sexually transmitted diseases Psychiatric treatment Alcohol/drug use Mental illness I understand that I do not have to sign this authorization in order to get health benefit (treatment, payment, enrollment or eligibility for benefits) except if I receive healthcare when the sole purpose of the healthcare is to create health information for a third party. I understand that: A) I must revoke my authorization in writing and do so by completing and signing the Revocation of Authorization Form available at Swofford & Halma Clinic (SHC); B) If I revoke my authorization, it will not affect any actions already taken by SHC based upon this authorization, and C) I may bo be able to revoke this authorization if the purpose of it was to obtain insurance. Once SHC has disclosed health information, the recipient may re-disclose it in some situations. Privacy laws may no longer protect the information. I understand that this authorization does not permit the release of information related to health care provided to me more than 90 days after the date of this authorization. This prohibition does not extend to insurance companies. This authorization will expire 90 days from the date of signature. *** This is not a transfer of care; patient's application is in the process of being review. ***Signature of Patient or Patient's Authorized Rep. First Last Relationship Health QuestionnaireName First Last Age What medications are you taking regularly?Name: Dose: Name: Dose: Name: Dose: Are you allergic to any medication or foods? Please listPreferred Pharmacy List any surgeries: (example: appendix, gallbladder, hysterectomy, etc.)Name Date Hospital List any major illnesses: (diabetes, high blood pressure, heart trouble, chroning lung problem, cancer)Name Date Hospital List serious injuriesWhat happened Date Hospital What happened Date Hospital VaccinationsHave you completed all of the usual childhood immunizations (diphteria, tetanus, whooping cough, oral polio, measles, mumps, and rubella)? When was your last tetanus booster? Do you usually receive a yearly influenza ("flu") shot? If you work in a health care facility or institution, have you received hepatitis B vaccination? MotherAge Deceased Illness FatherAge Deceased Illness Brother(s)How Many Age Deceased Illness Sister(s)How Many Age Deceased Illness Children(s)How Many Age Deceased Illness List any family members with cancerRelationship Type of Cancer Relationship Type of Cancer Personal HistoryPresent Marital Status Religious preference? Occupation Spouses occupation Hobbies or Interest Healthy HabitsRecreational Drug (i.e.; marijuana, cocaine, etc) Do you smoke? Packs per day Duration (how long) yrs Do you drink? Wine, Beer, Mixed Drinks) How much alcohol do you consume on a regular basis? Do you drink caffeine (soda, coffee, energy drinks)? How many? Do you take or obtain alternative medicine (chiropractor, massage, herbal, etc.)? Do you have financial or stressful family problems which may be affecting your health? Obstetrical History (women only)Dates of Pregnancies and DeliveriesHave you had any miscarriages cr abortions? What birth control method are you using? Δ