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Child and Family Agency

Child and Family Agency

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Forms – CBC Adult Enrollment


Community Bridge Clinic Enrollment - Adult

Patient Information

Full Legal Name of Person Receiving Services(Required)
MM slash DD slash YYYY
Address(Required)
Sex(Required)

Ethnicity(Required)
Race(Required)

I agree voicemail messages can be left for me on:(Required)
Have you seen this dentist/group in the last year?

Insurance Information

Do you have insurance (private/Medicaid/Husky)?(Required)
Insurance Address
Policy Holder Name(Required)
MM slash DD slash YYYY
Is there additional insurance?(Required)
Insurance address(Required)
Policy Holder Name(Required)
MM slash DD slash YYYY

Emergency Contacts

Emergency Contact 1 - Name
Emergency Contact 2 - Name

Other contacts

Please list others with whom we may discuss your medical care, including family members and other providers.

Medical History

MM slash DD slash YYYY
Do you have any medical conditions?(Required)
Do you take any medications (including inhalers or vitamins)?(Required)
Have you had any serious injuries (including a head injury)?(Required)
Do you have a birth or heart defect?(Required)
Have you ever been hospitalized overnight?(Required)
Have you had any surgeries in the past?(Required)
Do you have any problems with sleeping and/or snoring?(Required)
Have you had a dental cleaning within the past 6-12 months?(Required)
MM slash DD slash YYYY
Does anyone smoke in the home?(Required)
Do you smoke, use e- cigarettes, or chew tobacco?(Required)
Do you get 60 min of exercise at least 3 times a week?(Required)
Are you concerned with the amount of time you spend on social media, T.V., video games, computer, or phone?(Required)
Do you have concerns about your health or weight?(Required)

Patient History of the Following:

Anemia/Blood disorders(Required)
Asthma(Required)
Alcohol/substance abuse(Required)
Cancer/Leukemia(Required)
COVID 19(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Digestive issues/Diarrhea/Constipation(Required)
Headaches/Migraines(Required)
Gynecologic issues (for women)
Seasonal Allergies(Required)
Heart murmur(Required)
Skin problems (eczema, acne, etc.)(Required)
Seizures(Required)
Overweight or Obesity(Required)

Family History - Please Note Relationship to Patient

Anemia/blood disorders(Required)
ADD/ADHD(Required)
Asthma(Required)
Cancer/Leukemia(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Headaches/ Migraines(Required)
Overweight/ Obesity(Required)
Skin problem (acne, eczema, etc.)(Required)
Mental Health Issues(Required)
Seizures(Required)
Heart Disease(Required)
Hypertension(Required)
Substance Use(Required)
Tobacco Use(Required)

Allergies

Any foods (including lactose intolerance)?(Required)
Any medications? (including over the counter or antibiotics)(Required)
Do you have an Epi-Pen (or similar prescription) for use in case of anaphylaxis?(Required)

Behavioral Health

Have you ever received counseling services(Required)
Are you interested in receiving information about mental health counseling?(Required)

Have you recently had any of the following:

Family changes(Required)
Work issues(Required)
Social/peer stresses(Required)
Anxiety/Panic Attacks(Required)
Anger issues(Required)
ADHD/Attention issues(Required)
Depression(Required)
Recent loss/crisis(Required)
By signing below, I understand and acknowledge I have read and understand this consent:(Required)
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION
I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to my health. I will notify the Community Bridge Clinic of any changes to medical information. By signing below, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent.
MM slash DD slash YYYY
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