RVLA Scholar Intake Form

Emergency Contact

Emergency Phone

Relationship

Please list the name(s) of your parent(s)/guardian(s):

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Which way would you prefer our clinic contact you?

If you would like us to communicate with you via a phone number or email that is different than listed above, please enter it here:

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What are your most important health concerns? Please list your health concerns or symptoms:

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Please describe if there are any accommodations our clinic can make for you (for example, magnifying glasses if you are visually impaired, assistance with filling out forms, dimming fluorescent lighting, etc.):

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Please list allergies to drugs, foods, or environmental factors and your reactions below:

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Do you take any of the following medications? If yes, please check them below:

Yes

Pain relievers (aspirin, ibuprofen, etc)

Cortisone (creams or pills)

Antibiotics

Sleeping pills

Antacids

Laxatives

Are you currently taking any prescription medications, over-the-counter medications, vitamins or other nutritional/herbal supplements?

Yes

If yes, please list them below:

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What hospitalizations, surgeries, injuries, accidents, or serious illnesses have you had?

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When was your last physical exam and/or blood work done?

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If you struggle with any of the following please check below:

Substance abuse

Suicidal thoughts

Cutting/self harm

Eating disorders

What do you do to manage your stress levels/what is your favorite thing to do?

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Many families are having a hard time. Are there additional life stressors on your family? Please check below if so.

Housing

Food

Legal/court system

Racial discrimination

Domestic violence

Employment

Medical issues in the family

Other

If other, please describe here:

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What is your race or family background?

Black/African/African-American

Latino

Pacific Islander

Asian

White

Decline to identify

American Indian/Alaska Native/Native Hawaiian/Enrolled Citizen- please list tribe below

Prefer to self describe- please type in below

Please describe/put more detail here:

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Is your family 1st or 2nd generation immigrants or refugees?

Yes

Do you have a personal or family history of the following?

No to all

Yes- please select all that apply

If other please describe below:

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Do you have any of the following symptoms/conditions?

No to all

Yes - please check below

Irregular periods

Painful menses

Abnormal bleeding

Breast tenderness

PMS

What type of birth control do you use, if any:

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Are you generally concerned about the cost of medical bills and/or copays?

Yes

Do you have health insurance?

Yes- please fill out more info below

In the next section, if you are unsure of what insurance you have or which policy it is, please choose "other" in the drop down menu and write "unknown" under policy.

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

What is the name of your dental insurance?

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What is the policy number for your dental insurance?

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Intake Form Agreement (Review Required)

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HIPAA Notice of Privacy Practices (Review Required)

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