Name: Swofford & Halma Clinic
Address: 2303 Reith Way, Sunnyside, WA, 98944
Telephone: 509-837-3933

Download New Patient Form

or fill the form below

Patient's Name / Nombre del paceinte*

First Last

Date of Birth / Fecha de naciemiento*

Phone Number / Numero de telefono

Is 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

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 transferencia

Type 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?

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 clinica

AUTHORATION TO RELEASE HEALTHCARE INFORMATION

Social Security #

I HEREBY REQUEST AND AUTHORIZE THE FOLLOWING RELEASE OF INFORMATION

INFORMATION RELEASED TO:
Swofford and Halma Clinic, Inc.
2303 Reith Way
PO BOX 119
Sunnyside, WA 98944
Phone # 509-837-3933
Fax # 509-837-3885

INFORMATION TO BE SENT FROM

Purpose, must check all that apply*

The following records are requested for release: Must Initial all that apply*

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:*

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 Questionnaire

Name

First Last

Age

What medications are you taking regularly?

Name:

Dose:

Name:

Dose:

Name:

Dose:

Are you allergic to any medication or foods? Please list

Preferred 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 injuries

What happened

Date

Hospital

What happened

Date

Hospital

Vaccinations

Have 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?

Mother

Age

Deceased

Illness

Father

Age

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 cancer

Relationship

Type of Cancer

Relationship

Type of Cancer

Personal History

Present Marital Status

Religious preference?

Occupation

Spouses occupation

Hobbies or Interest

Healthy Habits

Recreational 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 Deliveries

Have you had any miscarriages cr abortions?

What birth control method are you using?

AUTHORATION TO RELEASE HEALTHCARE INFORMATION

Health Questionnaire

Call Us Today