Health History and Duration of Service Agreement - English (1) General InformationName* First Last Date of Birth* Month Day Year Sex* Male Female Self-reported race: African American / Black American Indian / Alaskan Native Asian Caucasian / White Hispanic / Latino(a) Hawaiian / Pacific Islander AllergiesAre you allergic to any of the following?:*Check all that apply. Medications Food Latex Environment Other No allergies Allergies*Provide specific information about any allergies you have.Medical HistoryDo you have a medical history of any of the following?Acid Reflux* Yes No Arthritis* Yes No Asthma* Yes No Asthma - Do you use an inhaler?* Yes No Back Trouble* Yes No Bladder Infection* Yes No Cancer* Yes No Chronic Cough* Yes No Chronic Headache* Yes No Chronic Skin Rash* Yes No Constipation* Yes No Cough with Blood* Yes No Diabetes* Yes No Diabetes - Do you use insulin?* Yes No Dizziness/Faintness* Yes No Epilepsy* Yes No Gall Bladder Trouble* Yes No Heart Trouble* Yes No High Blood Pressure* Yes No Kidney Trouble* Yes No Mental Illness* Yes No Recent Weight Loss* Yes No Rheumatic Fever* Yes No Seasonal Allergies* Yes No Seizures/Convulsions* Yes No Shortness of Breath* Yes No Stroke* Yes No Swollen Ankles* Yes No Sexually Transmitted Diseases* Yes No Tuberculosis* Yes No Ulcers* Yes No List any Chronic Illnesses:*If none, enter "None." List any past Surgeries:*If none, enter "None." List any past Fractures or Injuries:*If none, enter "None." List any Other Health Related Problems:If none, enter "None." Do you smoke cigarettes?* Yes No How many per day?* How many years have you smoked?* Do you drink alcoholic beverages?* Yes No How many per week?* Do you use recreational drugs?* Yes No Which recreational drugs do you use?* ImmunizationsImmunizations*Have you received any of the following immunizations/vaccines? CHECK ALL THAT APPLY. Chicken Pox DPT Measles Polio Seasonal Flu Tetanus Other None Other immunizations/vaccines.*List other immunizations/vaccines that you have had. Current Medical Care / MedicationsList any medical providers that have seen in the past two (2) years:*If none, enter "None." List any clinics/hospitals where you currently/most recently receive health care:*If none, enter "None." List any medications you are currently taking (prescribed and over the counter). Press the + sign on the right to add more medications.*If none, enter "None."Medication NameDoseFrequency Self-ExamsDo you do monthly breast self-exams?* Yes No Have you every had a mammogram?* Yes No Would you like info on any health issues? (Female)* Yes No What health information would you like?* Do you do testicular self-exams?* Yes No Would you like info on any health issues? (Male)* Yes No What health information would you like?* Family History of IllnessesList any illnesses that have caused death or disability to family members. Press the + sign on the right to add more family members.*If none, enter "None."Family Member Relationship to YouIllnesses (e.g. diabetes, cancer, high blood pressure, etc.) Service Agreement: Please check each box to acknowledge that you have read and understood each policy.Eligibility* All patients at the LAFC are screened for eligibility the first time they are seen and annually for the duration of services. Eligibility at the LAFC is based on 1.) Waukesha County (and/or Oconomowoc School District) residency 2.) Lack of health insurance 3.) Income at or below 250% of the Federal Poverty Level. LAFC requires patients provide eligibility verification documents such as, photo ID, address verification, most recent tax return, W-2 form, most recent pay stub, etc. Patients are expected to let the LAFC know of any changes to residency, insurance, and income.Medications* LAFC provides medications at no cost to patients. Patients may be given medication samples, a prescription to be filled at local Oconomowoc and Waukesha Pick 'N Save pharmacies, or enrolled in a Patient Assistance Program (PAP) through a pharmaceutical company. LAFC pays for the prescriptions filled at pharmacies with donated funds.Medical Services* ProHealth care and Aurora health care systems provide select services such as CT, MRI, x-ray, and lab to LAFC patients at no cost. Other services require that patients enroll in financial assistance programs through the health systems. There may be costs to these services.Health Insurance* All patients at the LAFC will be screened for and provided information and assistance with health insurance enrollment if eligible.Patient Signature*By typing my signature, I acknowledge that I am aware aware of this policy. Date* MM slash DD slash YYYY CAPTCHA
