RVLA Adult Intake Form
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Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
REASON FOR VISIT
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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Would you like a medical interpreter?
No
Yes
If yes, what language?
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HEALTH INFORMATION
Do you have any allergies?
No
Yes
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:
No
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?
No
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:
No
Yes
In the past
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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LIFE STRESSORS
Many families are having a hard time. Are there additional life stressors on your family? Please check below if so.
Not currently an issue
On the edge but managing
Currently a stressor
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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BACKGROUND
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 or put more detail here:
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Is your family 1st or 2nd generation immigrants or refugees?
No
Yes
HEALTH HISTORY
Do you have a personal or family history of the following?
No to all
Yes- please select all that apply
Anemia
Damaged heart valve
Arthritis
Asthma
Hay fever/hives
Stroke
Kidney disease
Cancer
Heart disease
Mental disorder
Thyroid problems
Diabetes
High blood pressure
Sickle cell disease
Hepatitis
Liver disease
Tuberculosis
HIV
Other major disease
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
Cold hands/feet
Numbness/tingling
Muscle aches
Neck pain/stiffness
Back pain or sciatica
Shooting pain
Burning pain
Migraines or headaches
Shortness of breath
Frequent colds
Stomach aches
Anxiety or depression
ADHD
Low blood pressure
Easy bruising/bleeding
Night Sweats
Loss of memory
Frequent urination
Skin color changes
Skin rashes
Skin lumps
Loss of hair
Diarrhea
Constipation
Heartburn
Fainting
Chest pain
Weakness
Cramping
Joint pain
Sore throat
Fever
Cough
Fatigue
Murmur
Dizziness
Seizures
Jaw pain
Itching
Acne
Eye problems
Sinus problems
Head injury
Sleep problems
Stress/irritability
STI
Prostate issues
HEALTH HISTORY
Do you have any of the following?
No to all
N/A
Yes- please check below
Irregular periods
Painful menses
Abnormal bleeding
Breast tenderness
PMS
Are you currently or possibly pregnant?
No
N/A
Yes
Unsure
What type of birth control do you use, if any:
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Do you have any of the following?
No to all
N/A
Yes- please check below
Hernia
Testicular mass
Discharge
Insurance/Billing Info
Are you generally concerned about the cost of medical bills and/or copays?
No
Yes
Do you have health insurance?
No
Yes- please fill out next section
Insurance
I have insurance
Insurer
Aetna
Amerigroup
Asuris
BCBS Illinois
Cigna
Community Health Plan of WA
First Choice Health Network
Humana
Kaiser Foundation Health Plan of Washington
Lifewise of Washington
Medicaid/State/Apple Health
Molina
Other
Premera
Regence BSWA
Regence Group Administrators (RGA)
Tricare
United Healthcare
Policy Name
Policy / Group / Plan #
Member ID / Certificate #
Policy Holder
I'm not the policy holder.
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov / State
Postal / Zip Code
Phone Number
Dental Insurance
Do you have dental insurance?
No
Yes- please fill out more info below
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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