Healthcare Screen Assessment

HEALTHCARE SCREEN ASSESSMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Visit / Screening Details

Screening Date:

Clinical Measurements

Medical History

Diabetes    Hypertension    Asthma/COPD    Heart disease    Kidney disease    Other

Behavioral / Mental Health Screening

In the past two weeks, have you frequently felt down/depressed?    Yes No

Thoughts of harming yourself or others?    Yes No

Assessment / Findings

Refer to primary care provider    Urgent evaluation    Emergency department    Schedule follow-up appointment

Patient Consent and Privacy Acknowledgment

By signing below I attest that the information I have provided is accurate and complete to the best of my knowledge. I consent to the screening procedures described above, including collection of vital signs and brief clinical assessment. I understand that the results and notes will be recorded in my medical record and may be shared with other treating providers as necessary for my care.

I acknowledge that I have received the practice's privacy notice describing how my protected health information may be used and disclosed and my rights regarding that information. I understand that I may revoke this consent in writing except to the extent that action has already been taken in reliance on it.

I authorize the release of my screening results and related clinical information to the following person(s) or entities for coordination of care:

This authorization expires on:

Certification

I certify under penalty of law that the information provided on this Healthcare Screen Assessment is true and correct to the best of my knowledge. I understand that falsifying information may have consequences for clinical decision-making and billing.

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