Healthcare Health Screen Form

HEALTH SCREEN FORM

Patient Name:    DOB:    Gender:

Patient Information

Insurance Information

Vitals / Screening Measurements

Height:    Weight:    Blood Pressure:

Pulse:    Temperature:    Oxygen Saturation:

Current Medications & Allergies

No known allergies

Medical History / Chronic Conditions

Please check any conditions you have been diagnosed with:

Diabetes    Hypertension    Heart disease

Asthma / COPD    Kidney disease    Liver disease

Cancer    Mental health condition    Other:

Social History

Tobacco use:    Current    Former    Never

Alcohol use:    Recreational drug use:

Symptoms / Screening Checklist

Indicate current symptoms or exposures (check all that apply):

Fever or chills    Cough    Shortness of breath

Chest pain    New neurological symptoms (weakness, numbness)    Nausea, vomiting, or diarrhea

Loss of taste or smell    Recent known exposure to contagious illness    Travel in last 14 days

Immunizations

Consent, Authorization, and Acknowledgment

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize healthcare providers and staff to perform routine examinations and medically necessary procedures as deemed appropriate by my treating clinician. I understand that all treatment carries some degree of risk and that no guarantees have been made regarding outcomes.

I authorize the release and exchange of my medical information, including protected health information, to other healthcare providers, insurance companies, and entities involved in my care for purposes of treatment, payment, and health care operations. This authorization includes records related to communicable diseases, mental health treatment, substance abuse treatment, and HIV/AIDS where applicable, unless I have indicated restrictions below.

I have received and read the facility's privacy practices and patient privacy notice and acknowledge that I may request a copy of the notice. I understand my rights to inspect and request amendment of my protected health information as provided by law.

I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization. This consent remains in effect until the authorization expiration date specified above or until revoked in writing.

Warning: Providing false information or intentionally omitting relevant medical history may result in harm and may affect the medical care provided. Misrepresentation may also affect insurance coverage and billing.

Additional Notes (Clinician Use)

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