RFCC Clinical Intake Form (Provider RFCCs)

RURAL/FRONTIER WOMEN’S HEALTH COORDINATING CENTERS

UTAH NAVAJO HEALTH SYSTEM, INC.

RURAL/FRONTIER COORDINATING HEALTH CENTER

Women’s Health-Sáanii bits‘ iis baa a’ha yáá

Sponsored by the U.S. Department of Health and Human Services

Name__________________________________________

Birth Date_______________________________________

Home phone__________________ Work phone_________________ Email_____________________________

Please list a contact person and telephone number, in case of emergency:

Where have you been receiving your medical care?

Name of Physician:

Address:

^{Street Address City State Zip Code}

^{D o you use traditional Native Healing? If so, check which ones you use. NAC Traditional (list what type) _____________________}

^{__________________________________________}

^{A re you currently: Married Divorced/Separated Single L iving with Significant Other Widow}

^{How many are living in your home?_______________}

^{Do you have a problem paying for medical care? Yes No}

Do you have health insurance? None Private Medicare Medicaid IHS Other

PAST MEDICAL HISTORY: Please circle Yes or No for any illnesses that you have had:

AIDS/HIV	Yes	No		Kidney Disease	Yes	No
Anemia	Yes	No		Liver Disease	Yes	No
Arthritis	Yes	No		Lung Disease	Yes	No
Asthma/Bronchitis/Emphysema	Yes	No		Measles	Yes	No
Bleeding/Bruising easily	Yes	No		Mumps	Yes	No
Blood Disorder	Yes	No		Mental Illness	Yes	No
Cancer (type)	Yes	No		Pneumonia/Pleurisy	Yes	No
Crohn’s/colitis	Yes	No		Sinus Problems	Yes	No
Depression	Yes	No		Skin Disease	Yes	No
Diabetes	Yes	No		Stroke	Yes	No
Drug/Alcohol dependency	Yes	No		Rheumatic Fever	Yes	No
Eating Disorder	Yes	No		Stomach Ulcers	Yes	No
Epilepsy/Seizures	Yes	No		Thyroid Disease	Yes	No
Gout	Yes	No		Tuberculosis	Yes	No
Hay Fever	Yes	No		Depression or Anxiety	Yes	No
Hearing Problems	Yes	No		Other	Yes	No
Hepatitis	Yes	No			Yes	No
High Blood Pressure	Yes	No			Yes	No
Immune Disorders	Yes	No			Yes	No
Intestinal Problems	Yes	No			Yes	No

Have you ever been hospitalized or had any surgeries □Yes □No If yes, please list the date(s) and reason(s):

Please list any medications you take, including prescription drugs, over-the-counter drugs, eye drops, vitamins, minerals, and herbs:

Name of Medication (s), herbs or vitamins Dose or Strength How often do you take it?

Have you ever had an allergic reaction to a medication(s)? □Yes □No If yes, which medication(s)?

Medication Reaction

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Other Allergies (foods or other substances)________________________________________________

FAMILY HISTORY: Have any members of your family, (including grandparents, parents, siblings, or children), had any of the following?

Problem	Circle Yes or No		Family Relationship
Alcoholism / Substance Abuse	Yes	No
ALS (Lou Gehrig’s Disease)	Yes	No
Alzheimer’s / Dementia	Yes	No
Anemia / Bleeding Problems	Yes	No
Cancer (Breast, Ovarian, Colon, Other)	Yes	No
Depression / Other Mental Illness	Yes	No
Diabetes	Yes	No
Heart Disease / Angina	Yes	No
Hepatitis / Liver Disease	Yes	No
High Blood Pressure	Yes	No
High Cholesterol	Yes	No
Kidney Disease	Yes	No
Mental Illness	Yes	No
Migraine	Yes	No
Osteoporosis	Yes	No
Seizure Disorders	Yes	No
Stroke	Yes	No
Thyroid Disease	Yes	No
Tuberculosis	Yes	No
Other (Please describe)	Yes	No

SOCIAL HISTORY: Please tell us about your lifestyle and personal habits. It is OK if you choose not to answer any of these questions.

What is your occupation Employer____________________________

Sometime people have difficulty learning, understanding, or following their treatment plan. This may be due to difficulty reading, language, cultural issues,

v isual or other physical problems. Do you have any such concerns? No Yes

What is your primary language?_________________________

What is your highest education level in school?_____________

Do you live alone? □ Yes □ No If no, whom do you live with?

Do you follow any special diet? □ Yes □ No If yes, describe:

Do you have concerns about your nutrition? □ Yes □No If yes, describe:

Do you exercise regularly? □Yes □ No If yes, describe:

If the answer is yes how many times of the week do you exercise_____________________________________

Rate the level of stress in your life (circle) 0 1 2 3 4 5 6 7 8 9 10

No stress Very High stress

Race/ethnicity □ Native American □ Caucasian (White) □ Hispanic □ Asian American □ Other

Do you/have access to a car? □ Yes □ No If the answer is no, who brings you to the clinic?_________________

Do you use chewing tobacco or snuff? □ Yes □ No Do you smoke cigars or cigarettes? □ Yes □ No

If the answer is Yes, answer the questions below:			If the answer is No, answer the questions below:
How many years have you smoked?			Have you smoked in the past?	Yes	No
How many packs per day do you smoke?			How many packs per day did you smoke?
Are you interested in quitting?	Yes	No	When did you quit?

Do you drink alcohol? □ Yes □ No If yes, please answer the questions in the box:

During the last week, on how many days have you had a drink?
On days when you had a drink, how many drinks (beer, wine, liquor) did you have?
Have you ever felt that you ought to cut down on your drinking?	Yes	No
Have people criticized your drinking?	Yes	No
Have you ever felt bad or guilty about your drinking?	Yes	No
Have you ever had to have a drink first thing in the morning to steady your nerves or get rid of a hangover?	Yes	No
Have you ever had blackouts or memory loss?	Yes	No

Do you use or take any drugs such as marijuana, cocaine, stimulants, or sedatives? □Yes □No

If yes, describe: Have you ever injected any drugs? □Yes □No

Risk factors for infection with HIV, the AIDS virus, include anal intercourse or vaginal intercourse with multiple partners, intravenous drug use, hemophilia, past history of a blood transfusion between 1979-1985, and sexual contact with an HIV-positive individual or other person with these risk factors. If you have any of these risk factors, or are interested in being tested for HIV infection, please discuss this with your health care provider.

How old were you when you had your first menstrual period? Age__________

Do you still have periods? No Yes

If the answer is yes are your periods: (Check all that apply)

• Regular Irregular Painful/cramps

Days of period__________ Length of cycle__________

First day of your last period______________

Number of : Pregnancies ____ Miscarriages ____ Abortions ______ Live births _______

Do you currently use any form of birth control? No Yes

If yes, please state type that is used______________________

Have you ever been on hormone replacement? No Yes

If yes, give dates and type____________________________________

Do you have problems with: Vaginal discharge Hot flashes Vaginal dryness Sexual problems

REVIEW OF SYSTEMS:

Have you experienced any of the following in the past 3-6 months? Please check the box.
	Change of health		Nausea/vomiting		Urine leakage with exercise		Leg pain		Rashes/skin problems
	Weight changes		Peptic ulcer		Painful urination		Varicose veins/phlebitis
	Asthma/Wheezing		Abdominal pain		Recurrent urinary tract infections		Swollen ankles//hands
	Heartburn		Jaundice/Hepatitis		Blood in urine		Numbness
	Sore throat		Diarrhea		Confusion		Joint/muscle stiffness/pain/weakness
	Hoarseness		Constipation		Coughing up blood
	Difficulty swallowing		Diverticulosis		Chronic cough		Memory loss
	Sinus problems		Shortness of breath on exertion		Hair loss		Tremor/hands shaking
	Pain or irritation in eye(s)		Bloody/tarry stools		Bruise easily		Neck/Back pain
	Change in hearing/ringing		Hemorrhoids		Chest pain		Bone fracture
	Vision problems		Hernia		High blood pressure		Headaches
	Problems with teeth/gums		Frequent urination		Irregular heart/palpitations		Recurrent fevers or chills
	Numbness/tingling		Headaches		Delayed healing		Difficulty sleeping

Have you ever had a mammogram? No Yes

If yes date____________ where___________

Have you had an abnormal mammogram? No Yes

If yes date____________ results__________________

When was your last PAP Smear? Date_________________

Have you ever had an abnormal PAP Smear? No Yes

If yes, please give date___________ treatment____________

Have you had a Dexiscan? (test to check for bone density) No Yes

If yes, please give date_________________

Have you ever felt threatened or hurt by someone?	Yes	No
During the past month, have you felt “down” or depressed ?	Yes	No
Do you have trouble finding pleasure in things you used to enjoy?	Yes	No
Have you ever been so sad that you thought about hurting yourself?	Yes	No

If you are older than age 65 or have any chronic medical condition(s) please answer the following:

Do you have any difficulty bathing or dressing yourself? □Yes □ No

Do you ever lose control over your urination or bowel movements? □Yes □ No

Have you had 3 or more falls in the past year? □Yes □ No

Have you experienced any changes in your ability to do your usual activities? □Yes □ No

Are you receiving any special help at home? □Yes □ No

An Advance Health Care Directive is a document that provides instructions regarding your medical care in the event of serious medical problems. It also allows you to define who may make health care decisions for you if you are unable to make decisions for yourself. It has previously been called a “Living Will” or “Durable Power of Attorney for Health Care.”

Do you have an Advance Health Care Directive? □Yes □ No

If no, would you like information about Advance Directives? □Yes □ No

What healthcare services are you interested in?

	Mammography		Retinal Eye Exam		Public Health
	Bone Density Screening		Surgeon consul		Radiation Exposure Screening
	Audiology		Nutrition/Dietician		Recreation
	Behavior Health		Pharmacy		Nerve Conduction Assessment
	Dental		Physical Therapy		Orthopedics
	Diabetes		Podiatry		Depression
	Cardiovascular		Prenatal/OB		Medicaid Outreach
	Eligibility		Ultrasound		Exercise Stress Test
	Ankle Brachial Blood Screen		Traditional Medicine		Family Planning
	Cancer Screening		Domestic Violence		Well Child Care
	Weight Loss Program		Stress Management

Is there anything else you would like to tell or ask your provider?_______________________________

___________________________________________________________________________________

Instructions to Provider: Your signature below indicates that you have reviewed the information contained in this questionnaire and you have reviewed the pertinent or key findings with the patient and/or family. Key findings must be summarized in your progress note; however, the questionnaire may be referenced for additional details.

Signature________________________________________________ Date__________________________

UTAH NAVAJO HEALTH SYSTEM, INC.

CLIN/WOMEN’S HEALTH REGISTRATION

Updated & Approved 5/5/05

Navigant Consulting Inc. Appendix F-1

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