CLINIC APPLICATION. Client Information

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1 ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC Tel: (843) Fax: (843) Last Name Street Address City, State, Zip Code Home Phone (Optional) Emergency Contact Date of Birth CLINIC APPLICATION Client Information First Name Work Phone Phone Social Security Number MI Age Race Sex Marital Status S M W D Sep Resources Working? Yes No Employer Retired? Yes No From Where Do you have Veteran's Administration (VA) benefits? Yes No Disabled? Yes No Are you currently filing for disability? Yes No Are you currently filing for Workman's Compensation? Yes No Do you have Medicare? Yes No Do you have Medicaid? Yes No Are you currently filing for Medicaid? Yes No Do you have private health insurance? Yes No Company Are you covered by a spouse or parent's health insurance? Yes No

2 Financial Information Gross Income Salary/Wages $ /mo. If you have NO INCOME, how are you supported? Retirement/Pension $ /mo. Social Security (SSI) $ /mo. Disability $ /mo. Alimony $ /mo. Child Support $ /mo. Food Stamps/WIC $ /mo. Other $ /mo. TOTAL $ /mo. Spouse and Household Members Name How Related? Age Sex Employer or Source of Income Monthly Salary TOTAL HOUSEHOLD INCOME: per month per year How much do you spend on the following? Doctor's Visits Medications Other Medical Expenses /mo. /mo. /mo. I verify that the above information is correct. Signature of Patient or Guardian Date Screener Date

3 New Patient Questionnaire Name: Age: Marital S M Status: D W Employer: Position: Reason for Visit PREVENTIVE HEALTH Date of last: Date of last: Date of last: Date of last: Colonoscopy Gardasil Flu Vaccine Tetanus Pap Test Mammogram Rubella Bone Density Was last pap: Normal Abnormal Any previous abnormal Pap date Treatment PAST MEDICAL HISTORY: please check (X) ALL areas that apply to you. Vaginal Infections - History of : Yeast Trichomonas 7:1 Chlamydia Herpes Gonorrhea Arthritis High blood pressure Severe headaches Asthma Kidney/bladder problems Skin disease Anemia / blood disorder Mitral valve prolapse Stomach problems Bowel disorders Phlebitis Thyroid disease Diabetes Seizures/epilepsy Urinary incontinence Hepatitis Serious injuries Other Heart disease HOSPITAL ADMISSIONS or SURGERIES (excluding pregnancy) Year Description Year Description Medication Frequency of Dose Medication Frequency of Dose DRUG ALLERGIES REACTION DRUG ALLERGIES REACTION FAMILY HISTORY: Have any of your close relatives had any of the following conditions? Condition: Relation to you Maternal/Paternal Agia : Condition: Relation to you Maternal/Paternal Age Blood disorder High blood pressure Breast cancer Kidney disease Cancer Lung disease Diabetes Heart attack Ovarian cancer Stroke, Dog In order to provide the highest quality care possible, please complete this form entirely on the front and the back. Thank you.

4 /J SOCIAL HISTORY Smoking Yes No (# cigs. Per day? ) Alcohol Yes No Drinks/Week Street drui Yes No Caffeine Tea/Coffee cups/day Colas cans/day Exercise: None times per week Activity: Sexual History: Satisfactory 1=1 Uncomfortable Wish to discuss MENSTRUAL HISTORY Age at 1st period Date of last period (1st day) _ Period Interval (1st day to 1st day)4 of days Cramps Yes No Mild Moderate Severe Medication for cramps Duration of bleeding Menopausal Yes, I am Pre Post or No I have had a hysterectomy Contraceptive History Current Method: OBSTETRICAL HISTORY Past methods: Total Preg: Full Term Births Premature Births No. of Abortions Induced No. of Abortions: Spontaneous Ectopic Births Multiple Births (twins) Living Children Weeks Month / Day / Year Weight Sex Type of Delivery Remarks Prea. 1) 2) 3) 4) 5) 6) PLEASE CHECK (X) IF ANY OF THE FOLLOWING SYMPTOMS APPLY TO YOU CURRENTLY CONSTITUTIONAL CARDIOVASCULAR SKIN Weight loss EYES Weight gain Fever Fatigue Double vision Spots before eyes Vision changes Painful breathing Chest pain Difficult breathing on exertion Swelling of legs Palpitations of heart RESPIRATORY Wheezing Spitting up blood Rash Ulcers NEUROLOGIC Dizziness Seizures Numbness Trouble walking EARS, NOSE, THROAT Shortness of breath Muscle weakness BREASTS Ear aches Ringing in ears Sinus problems Sore throat Mouth sores Dental problems Pain in breast Discharge Masses Implants Cough, chronic MUSCULOSKELETAL ENDOCRINE GASTROINTESTINAL Dry skin Frequent diarrhea Bloody stool Nausea/vomiting Constipation GENITOURINARY Blood in urine Pain with urination Urgency Frequency of urination Incomplete emptying Stress incontinence Abnormal periods Painful intercourse Abnormal thirst Hot flashes PSYCHIATRIC Depression Frequent crying HEMATOLOGIC/LYMPHATIC Easy bruising Enlarged lymph nodes Easy bleeding

5 ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC Tel: (843) Fax: (843) I. Consent to receive medical services and/or treatment. I consent to receive medical services and treatment rendered by a physician, pharmacist, or nurse who has voluntarily agreed to provide such treatment without compensation or the expectation or promise of compensation as established in Section of the Code of Law of South Carolina. As part of my treatment, I understand that I may receive medications dispensed in sample packaging or non-childproof containers. Signature Date Witness II. Consent to Authorize Retrieval of Information I consent to allow this clinic to request my prior medical records from hospitals, clinics or doctor's offices where I have previously received treatment. Signature Date Witness III. Consent to share information with Patient Assistance Programs for the purpose of obtaining medications. In order to allow this clinic to obtain medication assistance for me, I consent to allow release of the information I have provided on the clinic application (such as resources, financial and household information) to pharmaceutical company Patient Assistance Programs. Signature Date Witness

6 ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC Tel: (843) Fax: (843) PRIVACY PRACTICES ACKNOWLEDGEMENT ACKNOWLEDGEMENT OF RECEIPT hereby acknowledge that ICNA Relief USA Shifa Free Medical Clinic, has given me the opportunity to read a detailed notice of their Privacy Practices. Patient Signature CONSENT TO RELEASE INFORMATION In the event I cannot be reached, I,, give permission for a representative from ICNA Relief USA Shifa Free Medical Clinic to speak with family member(s) or companion(s) listed below regarding care or tests results. Name Phone Relationship Name Phone Relationship Is it OK to leave results or information on your voic ? Yes No Patient Signature Date

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