Healthcare Health Self Assessment

HEALTHCARE HEALTH SELF ASSESSMENT

Patient Name:    Date of Birth:    Medical Record / ID #:

Contact & Demographic Information

Insurance Information

Presenting Symptoms & Screening

Please check any symptoms you are currently experiencing:

If any symptoms checked above, date of onset:

Exposure, Travel & Testing

Have you had close contact with a person known to have a communicable illness in the past 14 days?   Yes   No

Have you traveled internationally or to a high-risk area in the past 14 days?   Yes   No

Medical History

Functional & Safety Assessment

Current level of independence for activities of daily living:

Any fall or safety concerns in the past 12 months?   Yes   No

Privacy, Use of Information & Authorization

I certify that the information provided in this self assessment is complete and accurate to the best of my knowledge. I understand that information provided herein will be used by clinical staff to assess my condition and to determine appropriate care. I authorize the release and exchange of health information contained in this form for purposes of treatment, billing, and healthcare operations as permitted by applicable law. I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights regarding my health information.

I understand that I may revoke this authorization at any time by providing written notice to the facility, except to the extent that action has already been taken based on this authorization. This authorization will expire on the date provided below or, if no date is provided, one year from the date of signature.

Acknowledgment: I acknowledge I have read and understand the statements above and consent to the uses described.

Attestation

I certify under penalty of law that the information provided on this form is true and accurate to the best of my knowledge and belief. I understand that knowingly providing false information may subject me to penalties as provided by law.

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