Healthcare Screenings Form

HEALTHCARE SCREENINGS FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History

Screening Services Requested / Performed

Select screenings requested or performed (check all that apply):

Blood pressure measurement    Result:

Height and weight (BMI)    Height:    Weight:    BMI:

Point-of-care blood glucose    Result:

Lipid panel (cholesterol)    Result summary:

Complete blood count (CBC)    Result summary:

Urinalysis    Result summary:

Vision screening    Result:

Hearing screening    Result:

Tuberculosis screening (skin or IGRA)    Result:

HIV screening (opt-in)    If performed, Result:

Hepatitis C screening (opt-in)    If performed, Result:

Screening Clinician and Facility

Facility/Clinic Name:

Clinician Name:    License/ID:

Date of Screening:

Consent, Privacy, and Acknowledgments

I consent to the screenings requested above, including specimen collection, point-of-care testing and communication of results to me and to other healthcare providers as necessary for my care. I understand that screening tests are used to detect conditions early and that results that suggest further evaluation will be referred as noted in follow-up recommendations.

Risks and limitations: I acknowledge that screenings may produce false positive or false negative results, and that some tests require confirmatory testing. I have had the opportunity to ask questions and understand the nature and purpose of the screenings to be performed.

Withdrawal of consent: I understand that I may withdraw consent at any time prior to the collection of specimens or performance of procedures, except to the extent that actions have already been taken in reliance on this consent.

Authorization for release of results: I authorize release of screening results and relevant medical information to the following persons or organizations (list names and relationship). If none, leave blank.

Privacy acknowledgement: I acknowledge that I have been offered the facility's privacy practices notice and that my health information will be protected in accordance with applicable law. Information about communicable disease results may be reported to public health authorities as required by law.

Authorization expiration: This release and authorization for screenings and disclosure of results shall expire on: . If left blank, authorization will expire one year from the date signed unless otherwise required by law.

Patient Statements

I attest that the information I have provided on this form is accurate to the best of my knowledge. I understand the screening results will be communicated to me and documented in my medical record. I consent to necessary follow-up and referrals based on results.

Patient ability to consent: I affirm that I am competent to give consent for the screenings checked above. If signing as a legal guardian or authorized representative, I certify that I have legal authority to consent on behalf of the patient and will provide documentation upon request.

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