ICNA Relief USA Shifa Free Medical Clinic
1092 Johnnie Dodds Boulevard, Suite 108
Mount Pleasant, SC 29464
Tel: (843) 352-4580
Fax: (843) 375-9063
CLINIC APPLICATION
Client Information
Last Name
Street Address
City, State, Zip Code
Home Phone
Email (Optional)
Emergency Contact
Phone
Date of Birth
First Name
MI
Work Phone
Social Security Number
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
Spouse and Household Members
Name How Related? Age Sex Employer or Source of Income Monthly Salary
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.
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
Screener
Date
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
❑ Asthma
❑ Anemia / blood disorder
❑ Bowel disorders
❑ Diabetes
❑ Hepatitis
❑ Heart disease
❑ High blood pressure
❑ Kidney/bladder problems
❑ Mitral valve prolapse
❑ Phlebitis ❑ Seizures/epilepsy ❑ Serious injuries ❑ Severe headaches ❑ Skin disease ❑ Stomach problems ❑ Thyroid disease ❑ Urinary incontinence ❑ Other
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 Ag°: Condition: ia Relation to you Maternal/Paternal Age Dog
❑ Blood disorder ❑ High blood pressure
❑ Breast cancer ❑ Kidney disease
❑ Cancer ❑ Lung disease
❑ Diabetes
❑ Heart attack
❑ Ovarian cancer
❑ Stroke ,
/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 Moderate Yes, I
day) _ Period
❑ I
Interval (1st day to 1st day)4 of days
Cramps ❑ Yes ❑ No ❑ Mild
Duration of bleeding Menopausal
❑ Severe Medication am ❑ Pre ❑ Post or No
for cramps
have had a hysterectomy
Contraceptive History Current Method: Past methods:
OBSTETRICAL HISTORY
Total Preg: Full Term Births Premature Births No. of Abortions Induced
No. of Abortions: Spontaneous Ectopic Births Multiple Births (twins) Living Children Month / Day / Year Weeks
Prea. Weight Sex Type of Delivery Remarks 1) 2) 3) 4) 5) 6)
PLEASE CHECK (X) IF ANY OF THE FOLLOWING SYMPTOMS APPLY TO YOU CURRENTLY
CONSTITUTIONAL CARDIOVASCULAR SKIN
❑ Weight loss ❑ Weight gain ❑ Fever ❑ Fatigue ❑ Painful breathing ❑ Chest pain
❑ Difficult breathing on exertion
❑ Swelling of legs ❑ Palpitations of heart ❑ Rash ❑ Ulcers NEUROLOGIC ❑ Dizziness ❑ Seizures ❑ Numbness ❑ Trouble walking EYES ❑ Double vision
❑ Spots before eyes
❑ Vision changes RESPIRATORY ❑ Wheezing ❑ Spitting up blood ❑ Shortness of breath ❑ Cough, chronic MUSCULOSKELETAL
EARS, NOSE, THROAT ❑ Muscle weakness
❑ Ear aches ❑ Ringing in ears ❑ Sinus problems ❑ Sore throat ❑ Mouth sores ❑ Dental problems ENDOCRINE
GASTROINTESTINAL ❑ Dry skin
❑ Abnormal thirst ❑ Hot flashes ❑ Frequent diarrhea ❑ Bloody stool ❑ Nausea/vomiting ❑ Constipation PSYCHIATRIC ❑ Depression ❑ Frequent crying BREASTS GENITOURINARY ❑ Pain in breast ❑ Discharge ❑ Masses ❑ Implants ❑ Blood in urine
❑ Pain with urination
❑ Urgency ❑ Frequency of urination ❑ Incomplete emptying ❑ Stress incontinence ❑ Abnormal periods ❑ Painful intercourse HEMATOLOGIC/LYMPHATIC ❑ Easy bruising
❑ Enlarged lymph nodes