Adult New Patient Form

Patient Demographics
Thank you for choosing our office! In order to serve you properly, we need the following information. All information will remain confiential.
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
SSN

Optional
Gender*
- Male
- Female
Physical Address*
Street Address Address Line 2 City State ZIP Code
Is your mailing address different from your physical address?*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone (if different)
Email Address*

We will NOT use your email address for solicitation. It is for communication purposes via our patient portal only.
Preferred method of contact
- Cell Phone
- Home Phone
- Text
- Email
- Mail
Marital Status
- Married
- Single
- Divorced
- Separated
- Widowed
- Widowed / Remarried
- Significant Other
Are you a minor?*
- Yes
- No
Minor Information
Please list name of parent / guardian*
Parent / Guarantor Date of Birth
MM slash DD slash YYYY
Parent / Guardian's phone (if different)*

In Case of Emergency
Patient or Parent's Employer*
Work Phone*
Emergency Contact Name*
Emergency Contact Home Phone*
People who can call and receive patient medical information: (for confidentiality purposes)
Name Relationship Phone
Please select your primary medical provider in this office?
- Aaron Catmull | N.P.
- Charles Clair | M.D.
- Cameron McHan | N.P.
- Shawna McCaffrey | N.P.
- Brian Muir | D.O.
- Kevin Owens | M.D. F.A.C.P.
- Jeff Swenson | M.D.
- Casie Taylor | N.P.
- Tyson Steel | D.O.
- Brad Wynn | D.O.
- Sara Zielinski | N.P.
Do you have primary health insurance information you'd like to submit?*
- Yes
- No
Primary Insurance
Name of Insured
Birth Date of Insured
MM slash DD slash YYYY
Relationship to Patient
SSN of Insured
ID Number
Group Number
Deductible / Co-Pay Amount
Deductible Co-Pay
Do you have secondary insurance information you'd like to submit?*
- Yes
- No
Secondary Insurance
Name of Insured
Birth Date of Insured
MM slash DD slash YYYY
Relationship to Patient
SSN of Insured
ID Number
Group Number
Deductible / Co-Pay Amount
Deductible Co-Pay
- I request that payment of authorized Commercial Insurance/Medicaid/Medicare/Medicare supplement benefits be made either to me, or on my behalf to Minidoka Medical Center/Rural Health Clinic for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to my insurance, or Centers for Medicare and Medicaid Services, and its agents any information needed to determine these benefits or the benefits payable for related services.
Consent to Treat*
- I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

Health History
Do you have any allergies to medications?*
- Yes
- No
Please list:
Medication you are allergic to What happens?
Are you currently taking any medications?*
- Yes
- No
What medications are you taking?*
Medications Strength How many times a day do you take it?
Please carefully review the list below and select a topic if either you or a member of your family has ever had any issues with the following: (select all that apply)
- Skin, hair, nails, and teeth
- Eyes, ears, nose, throat
- Heart problems
- Lungs / breathing problems
- Stomach problems
- Liver / pancreas problems
- Bowel problems
- Kidney problems
- Bladder problems
- Arthritis / Joint problems
- Weakness
- Stroke / Seizures
- Anemia / Bleeding problems
- Cancer
- Diabetes
- Thyroid Problems
Skin, Hair, Nails, And Teeth
Do you wear dentures?*
- Yes
- No
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Eyes, Ears, Nose, and Throat
Do you wear glasses?*
- Yes
- No
Do you wear hearing aids?*
- Yes
- No
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Heart Problems
Have you had a heart attack?*
- Yes
- No
Do you have high cholesterol?*
- Yes
- No
Do you have high blood pressure?*
- Yes
- No
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Has anyone in your family had a heart attack?*
- Yes
- No
Lungs / Breathing Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Stomach Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Liver / Pancreas Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Bowel Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Kidney Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Bladder Problems
Do you have urinary leakage?*
- Yes
- No
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Arthritis / Joint Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Weakness
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Strokes / Seizures
Have you ever had a stroke?*
- Yes
- No
Have you ever had a seizure?*
- Yes
- No
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Anemia / Bleeding Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Cancer
What type of cancer?*
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Diabetes
How long?*
Pills or Insulin?*
- Pills
- Insulin
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*
Thyroid Problems
Please describe YOUR medical history with these issues*
Please describe your FAMILY'S medical history with these issues*

Pregnancy Information
Have you been pregnant before?*
- Yes
- No
How many pregnancies?*
How many deliveries?*
When was your last menstrual period?*
Have you had a hysterectomy?*
- Yes
- No
When was your last pap smear?*
Have you had a mammogram before?
- Yes
- No
When was your last mammogram?*

Mental Health
Have you ever suffered from depression?
- Yes
- No
Have you ever suffered from anxiety?
- Yes
- No
Have you ever suffered from any other mental health problems?
- Yes
- No
Please explain*
Please describe YOUR medical history with these issues
Please describe your FAMILY'S medical history with these issues

More medical history
Please list any and all previous doctors and hospitals that have provided medical care for you
Name of Doctor City they are located
Do you have any previous hospitalizations?*
- Yes
- No
Please explain*

Family History
Is your father*
- Living
- Deceased
How old when he passed away? And why?*
Father's health conditions (if any)
Is your mother*
- Living
- Deceased
How old when she passed away? And why?*
Mother's health conditions (if any)
Do you have any brothers?*
- Yes
- No
Please list*
Number of Brothers Health conditions
Do you have any sisters?*
- Yes
- No
Please list*
Number of Sisters Health conditions

Preventative
Please list the dates and results from these tests. If you don't have history taking it, please place a "N/A" in the text field.
Colonoscopy
Date Normal Abnormal Due Date
Bone Density
Date Normal Abnormal Due Date
Mammogram
Date Normal Abnormal Due Date
PAP
Date Normal Abnormal Due Date
PSA
Date Normal Abnormal Due Date
Eye Exam
Date Normal Abnormal Due Date
Foot Exam
Date Normal Abnormal Due Date
Rectal Exam
Date Normal Abnormal Due Date
Dental Cleaning
Date Normal Abnormal Due Date
Any surgical history and dates?

Social History
Occupation*
- Employed
- Unemployed
- Retired
- Homemaker
- Disabled
- Student
Place of Employment*
Marital Status*
- Married
- Single
- Divorced
- Separated
- Widowed
- Widowed but remarried
- Significant Other
Sexually Active? (select all that apply)*
- Yes
- No
- Multiple Partners
- Birth Control
- Condoms
- Other
Do you have children?*
- Yes
- No
How Many:
Male children Female children Miscarriages
What is your activity level?*
- Athletic
- Active / Fit
- Occasionally / Rarity
- Never
What is your ideal body weight?*
Tobacco Products / Nicotine*
- None
- Cigarettes
- Cigars
- Smokeless / Chew
- E-Cigarette / Vape
- Quit
How many a day?*
How many years smoked?*
What date did you quit?*
Alcohol Use (select all that apply)*
- None
- Daily
- Weekly
- Socially
- Rarely
- Beer
- Wine
- Hard Alcohol
Caffeinated Products*
- None
- Coffee
- Tea
- Soda Pop
- Energy Drink
Amount of coffee consumed daily:*
Amount of tea consumed daily:*
Amount of soda consumed daily:*
Amount of energy drinks consumed daily:*
Illegal Drugs (select all that apply)
- None
- Marijuana
- Methamphetamines
- Cocaine
- Other
How frequently do you use marijuana?*
- Experimented with
- Currently Use
- Quit
- Rehabilitation
- Self-Recovery
When did you quit using marijuana?*
How frequently do you use methamphetamines?*
- Experimented with
- Currently Use
- Quit
- Rehabilitation
- Self-Recovery
When did you quit using methamphetamines?*
How frequently do you use cocaine?*
- Experimented with
- Currently Use
- Quit
- Rehabilitation
- Self-Recovery
When did you quit using cocaine?*
Mental Health History (select all that apply)
- N/A
- Depression
- Anger Problems
- Bipolar
- Cutting
- Other
Was your depression:
- Treated
- Not Treated
Please list the doctor's name that treated your depression:*
Was your anger problems:
- Treated
- Not Treated
Please list the doctor's name that treated your anger problems:*
Was your bipolar disorder:
- Treated
- Not Treated
Please list the doctor's name that treated you for bipolar disorder:*
Was your cutting:
- Treated
- Not Treated
Please list the doctor's name that treated you for cutting:*
Communicable Diseases (select all that apply)*
- N/A
- Measles
- Mumps
- HIV / AIDS
- Hepatitis
- Other
What kind of Hepatitis*
- A
- B
- C
If "other", please explain:*
Code Status*
- Full Code | All lifesaving measures
- DNR | Do not resuscitate
- I do not know and would like to discuss
What pharmacy do you use?*
Pharmacy Name Location
Request for Medical Records*
- I would like to submit a request for transfer of medical records now
- I would like to gather this information and request transfer of medical records at a later date

Patient Rights and Responsibilities
WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RESPONSIBILITY TO:
- Treat the staff with consideration, respect and dignity.
- Understand that your life-style does affect your health.
- Take an active part in your health care.
- Follow the agreed upon treatment plan. If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider.
- Observe facility rules and regulations that are for the safety and consideration of all patients and staff.
- Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare.
- Report whether you understand a contemplated course of action and what is expected of you.
WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RIGHT TO:
- Be treated with consideration, respect and dignity;
- Have the confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in language you can understand;
- Have privacy during case discussion, counseling & treatment;
- Review your records in the presence of a healthcare professional;
- Know the name and qualifications of staff providing your care;
- Know your diagnosis, health problems, test results, the potential advantages and risks of treatment or procedures in language you can understand;
- Expect that all services, treatment and counseling techniques will take place with your informed consent;
- Participate in referral planning;
- Have access to the patient comment procedure;
- Refuse to participate in research.
- Have another individual present in the exam room with you, if you so desire.
I have read the copy of Patients Rights and Responsibilities*
- I agree
Release of information, treatment, privacy rights, and messages
Consent for Photograph*
- I consent to allow photography of myself for identification purposes, and for purposes of improving my medical care documentation (ie: wounds, lesions, etc)..
Authorization for Treatment*
- I hereby authorize, Minidoka Medical Center, and any assistants or associates that may be designated, to perform medical and hospital care to the above named patient
Privacy Practices / Discrimination*
- I have received/or declined copy of the Notice of Privacy Practices, and I have been provided an opportunity to review this entire document. Minidoka Memorial Hospital and Medical Center will not discriminate against a patient because of race, color, national origin, religion, ability to pay, or because a patient is covered by a program such as Medicaid or Medicare. If you feel you are a victim of discrimination you have the right to file written complaint to the Compliance Officer. Forms are available in the business office.
Consent to use of answering machine and/or voicemail messaging/email:*
- I hereby consent to the use of my answering machine and/or voicemail for the purpose of relaying important information regarding my treatment or care, including, but no limited to confirmation of appointments, changes in medication, results of lab tests, special instructions for testing procedures. I also consent to members of my family receiving this information in my absence. This consent will remain in effect until I rescind the consent in writing.
Signature
Phone*
Today's Date*
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Name	Relationship	Phone

Medication you are allergic to	What happens?

Medications	Strength	How many times a day do you take it?

Name of Doctor	City they are located

Step 1 of 10

Patient Demographics

Minor Information

In Case of Emergency

Health History

Skin, Hair, Nails, And Teeth

Eyes, Ears, Nose, and Throat

Heart Problems

Lungs / Breathing Problems

Stomach Problems

Liver / Pancreas Problems

Bowel Problems

Kidney Problems

Bladder Problems

Arthritis / Joint Problems

Weakness

Strokes / Seizures

Anemia / Bleeding Problems

Cancer

Diabetes

Thyroid Problems

Pregnancy Information

Mental Health

More medical history

Family History

Preventative

Social History

Patient Rights and Responsibilities

Release of information, treatment, privacy rights, and messages