Fillable Undergraduate New Patient Paperwork Na Phone Mail Email (St. Martin's College)

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Undergraduate New Patient Paperwork Na Phone Mail Email (St. Martin's College)

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The Undergraduate New Patient Paperwork Na Phone Mail Email (St. Martin's College) form is 3 pages long and contains:

  • 2 signatures
  • 84 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

U.S.A. forms for St. Martin's College

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Undergraduate New Patient Paperwork
Na
me (print): ___________________________________________ Date of Birth: __________________________
Today’s Date: __________________________
Current Address
(include city, state and ZIP code)
Current Phone Number
(include area code)
Home:
Office:
Cell:
Current Email Address
Preferred Method of Contact
Email
Phone Mail
Address on file with your insurance?
(include city, state and ZIP code)
Emergency Contact Name and
Relationship
Emergency Contact Phone Number
(include area code)
GENERAL INFORMATION
Marital status (check one)
Single Married Divorced
Status (check one)
1
st
year 2
nd
year 3
rd
year 4
th
year
Graduate Student ESL Faculty Staff
Are you in the U.S. military?
Yes No
Are you a Veteran with medical benefits?
Yes No
What is your SMU major?
Are you an international student?
What is your home country?
Are you an SMU athlete?
Yes No
What sport(s)?
ETHNICITY (mark all that apply)
American Indian or Alaska Native
Hispanic
Non-Resident Aliens
Asian
Multi-Ethnic
Undisclosed
Black or African American
Native Hawaiian or Other Pacific Islander
White
HEALTH INSURANCE INFORMATION OR PROVIDE YOUR CARD
Insurance company’s name:
Group Number:
Identification number:
Relationship to policyholder (self, spouse, parent, child, etc.) :
Is this insurance through: _____ SMU Plan _____ Your Parent(s)
_____ Parent(s) Employer _____ Your Employer
_____ Military _____ Other
Undergraduate New Patient Paperwork
Name (print): ___________________________________________ Date of Birth: __________________________
Today’s Date: __________________________
1. List all current medications (prescription strength and supplements): ________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2. Please record if you have been hospitalized or had surgeries in the past (and year occurred):
Appendectomy Orthopedic Surgery Tonsillectomy Other: ____________________________________
3. Please record any personal or family history of illnesses:
Self Family Self Family
Diabetes Kidney or Liver Disease
Heart Disease/Heart Attack Depression or Anxiety
High Blood Pressure Lung Condition (i.e. Asthma)
Cancer Other: _____________________
Cholesterol screening is advised for persons 20 years of age and older who have diabetes, heart disease, high blood
pressure, obesity (BMI >30), who smoke, have a family history of cardiovascular disease in male relatives younger than
50 or female relatives younger than 60.
If this applies to you, would you like your cholesterol checked? Yes No
4. Do you have any known allergies? ________________________________________ Yes No
5. If your B/P is greater than 135/80 you are at increased risk of Diabetes.
If this is your blood pressure would you like to be screened for Diabetes? Yes No
6. Have you smoked at least one cigarette in the past 30 days? Yes No
If yes to above, are you interested in quitting? Yes No
7. Over the past two weeks, have you felt down, depressed or hopeless? Yes No
Over the past two weeks, have you felt little interest or pleasure in doing things? Yes No
8. During the past two weeks have you had five or more (for men) or four drinks or more
(for women) containing alcohol (beer, wine or liquor) in a row, on at least one occasion? Yes No
In a typical week, do you drink on 3 or more occasions? Yes No
9. The CDC recommends all persons who have been sexually active to be tested for HIV.
Would you like an appointment for STI testing? Yes No
10. Women 21 and older are recommended to have PAP smears every 2 – 3 years.
Women 25 and younger are recommended to be tested for Gonorrhea and Chlamydia.
Would you like a Women’s Health appointment? Yes No
______________________________________________________ _______________
Patient Signature Date
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signature
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Undergraduate New Patient Paperwork
Optional Health Care Release of Information for Disclosure to Family or Other Individuals
I, ___________________________________________, authorize Saint Martin’s University Student Health Center to
disclose the following health care information: (please check box)
All health care information in my medical record, this DOES NOT include HIV/STD/Psychiatric/Drug/Alcohol related
information.
All health care information in my medical record, this DOES include HIV/STD/Psychiatric/Drug/Alcohol related
information.
Appointment information.
Test results.
Other (x-rays, bills, etc.) please specify.
__________________________________________________________________________________________________
Information may be shared with the following individuals:
Name Relationship
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________
Patient Signature
________________________________________________________
Printed Name
**This authorization is valid until Saint Martin’s University Student Health Center receives written revocation from the
patient.
This form will be retained in your medical record. Requests for changes may be made at any time.
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Undergraduate New Patient Paperwork Na Phone Mail Email (St. Martin's College)

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Completed 2 February 2021

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