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Garfield County Hospital District
Pomeroy Medical Clinic
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Pomeroy Medical Clinic New Patient Packet
Patient Demographics
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Indicates required field
Name
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First
Last
M.I.
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Social Security Number
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Date of Birth (XX/XX/XXXX)
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Physical Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell Phone Number
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Email Address (for portal setup)
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May we use your Cell Phone Number to notify you of upcoming appointments?
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Yes
No
May we use your Cell Phone Number to text you of upcoming appointments?
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Yes
No
Name:
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Relationship:
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If the patient is a minor child, or has a legal guardian, Please print that persons name and relationship
Health Insurance Type (Please choose)
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Self Pay (No Insurance)
Medicare
Medicaid
Commercial/Group
Other (Work Comp)
If Medicare/Medicaid ID Number#
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If Commercial/Group, Name:
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If Other (Work Comp), Name:
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Policy Number#
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Claim Number#
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Date of Injury (XX/XX/XXXX):
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New Patient Process
After you complete and return this form and any others included with this mailing, we will request your records from your previous provider(s). After we have received these records, our providers will review them and determine if the clinic can meet your needs. You will be contacted with that determination within 2-3 weeks and can schedule your first appointment at that time.
Patient History Form
Date (XX/XX/XXXX):
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Age:
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Sex
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Male
Female
Gender Identity:
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Male
Female
Non-Binary
Unspecified/Indeterminant
How did you hear about the clinic?
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Describe briefly your present symptoms:
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Please list the names of other practitioners you have seen for this problem:
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Psychiatric Hospitalizations (include where, when, & for what reason)
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Have you had psychotherapy?
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Yes
No
Drug Allergies:
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Yes
No
If yes, To what?
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Current Medications - Name, Dose (include strength and number of pills per day), How long have you been taking this?
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PAST MEDICAL HISTORY
Do you have or have you ever had:
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Diabetes
High Blood Pressure
High Cholesterol
Hypothyroidism
Goiter
Leukemia
Psoriasis
Angina
Heart Problems
Cancer (type)
Heart Murmur
Pneumonia
Pulmonary Embolism
Asthma
Stroke
Epilepsy (seizures)
Cataracts
Kidney Disease
Kidney Stones
Crohn's Disease
Colitis
Anemia
Jaundice
Hepatitis
Stomach/Peptic Ulcer
Rheumatic Fever
Tuberculosis
HIV/AIDS
None of these
Other Medical Conditions Please list:
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PERSONAL HISTORY
Were there any problems with your birth? (Specify)
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Where were you born and raised?
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What is your highest education?
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Completed High School
Some College
College Graduate
Advanced Degree
Other
Marital Status
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Never Married
Married
Divorced
Seperated
Widowed
Partner or Significant Other
What is your current or past occupation?
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Are you currently working?
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Yes
No
Hours a week:
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If not working, are you?
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Retired
Disabled
Sick Leave
Do you receive disability or SSI?
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Yes
No
If yes, for what disability & how long?
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Have you ever had legal problems? (Specify)
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Religion:
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FAMILY HISTORY
Father - Age, Health & Psychiatric, Age at Death (if applicable), If Deceased Cause
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Siblings - Age, Health & Psychiatric, Age at Death (if applicable), If Deceased Cause
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Mother - Age, Health & Psychiatric, Age at Death (if applicable), If Deceased Cause
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Children - Age, Health & Psychiatric, Age at Death (if applicable), If Deceased Cause
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EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT
Maternal Relatives:
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Paternal Relatives:
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SYMPTOMS REVIEW
In the past month, have you had any of the following problems?
General
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Recent weight gain
Recent weight loss
Fatigue
Weakness
Fever
Night Sweats
Nervous System
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Headaches
Dizziness
Fainting or Loss of Consciousness
Numbness or Tingling
Memory Loss
If Recent weight gain/loss, how much?
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Muscles/Joints/Bones
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Numbness
Joint Pain
Muscle Weakness
Joint Swelling
Where?
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Ears
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Ringing in ears
Loss of hearing
Blood
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Anemia
Clots
Eyes
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Pain
Redness
Loss of vision
Double vision
Blurred vision
Dryness
Psychiatric
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Depression
Excessive Worries
Difficulty Falling Asleep
Difficulty Staying Asleep
Difficulty with Sexual Arousal
Poor Appetite
Food Cravings
Frequent Crying
Sensitivity
Suicidal Thoughts/Attempts
Stress
Irritability
Poor Concentration
Racing Thoughts
Hallucinations
Rapid Speech
Guilty Thoughts
Paranoia
Mood Swings
Anxiety
Risky Behavior
Stomach/Intestines
*
Nausea
Heartburn
Stomach Pain
Vomiting
Yellow Jaundice
Increasing Constipation
Persistent Diarrhea
Blood in Stool
Black Stool
Throat
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Frequent Sore Throat
Hoarseness
Difficulty in Swallowing
Pain in Jaw
Kidney/Bladder
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Blood in Urine
Frequent or Painful Urination
Skin
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Redness
Rash
Nodules/Bumps
Hair Loss
Color Changes of Hands or Feet
Heart/Lungs
*
Chest Pain
Palpitations
Shortness of Breath
Fainting
Swollen Legs or Feet
Cough
Women Only
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Abnormal Pap Smear
Irregular Periods
PMS
Bleeding between periods
PCOS
Do you have regular periods?
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Yes
No
Age of first Period?
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# of Pregnancies
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# of Miscarriages
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# of Abortions
*
Have you reached menopause?
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Yes
No
If yes, Age?
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Other Medical Problems? (specify)
*
SUBSTANCE USE
Drug Category
Alcohol
Tobacco (cigarettes, cigars, pipes, chew, vape)
Cannabis (Marijuana, Hashish, Hash Oil)
Stimulants (Cocaine, Crack)
Stimulants (Meth-Speed, Ice, Crank)
Amphetamines/Other Stimulants (Ritalin, Benzadrine, Dexedrine, Benzodiazepines)
Tranquilizers (Valium, Librium, Halcion, Xanax, Diazepam, "Roofies", cloneazepam, Lorazepam)
Sedatives/Hypnotics/Barbiturates (Amytal, Seconal, Dalmane, Quaalude, Phenobartital)
Heroin
Street or Illicit Methadone
Other Opioids (Tylenol #2 & #3, 282's, 292's, Percodan, Percocet, Opium, Morphine, Demerol, Dalaudid)
Hallucinogens (LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy(MDMA), nitrous oxide)
Others (Specify)
Age when you first used this
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Do you currently use this
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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No
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Yes
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Yes
No
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Yes
No
Authorization to Release Patient HeaLth Information
This form may also be used for a patient to authorize the use or disclosure of their health information to GCHD/Pomeroy Medical Clinic from another organization.
Name
*
First
Last
Date of Birth (XX/XX/XXXX):
*
Previous Name (if applicable):
*
Reasons for this authorization (Check all that apply):
*
Personal use
Legal Use
Continuing Care
Transferring Care
Other (specify)
If other is selected:
*
Information to be Released From:
Organization or Company
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Fax
*
Information to be Released To:
Garfield County Hospital District
66 6th St, Pomeroy, WA 99347
Phone: (509)843-1591 Fax:
(509)843-1740
Information to be Disclosed/Released
GCHD/Pomeroy Medical Clinic may use or disclose the following healthcare information (check all that apply):
*
Entire Completed Chart Record
ED Reports
Clinic Visits
Radiology Reports
Lab Reports
Discharge Reports
Immunization/Shot Records
All Other Medical History (Please Specify):
*
If ED Reports (specify), All or Specify Dates
*
If Clinic Visits (specify), All or Specify Dates
*
If Radiology Reports (specify), All or Specify Dates
*
If Lab Reports (specify), All or Specify Dates
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If Discharge Reports (specify), All or Specify Dates
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Releasing Sensitive information - IMPORTANT
A minor patient's signature is required to release the following information; 1. Information related to reproductive care such as birth control, pregnancy related services and Sexually Transmitted Diseases, including HIV/AIDS (age 14 and older) 2. Substance abuse and mental health treatment (age 13 and older).
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Mental Health Treatment
Sexually Transmitted Disease
HIV/AIDS
Alcohol/Drug Abuse Treatment
My Rights as a patient of GCHD/Pomeroy Medical Clinic
Authorizing the disclosure of this healthcare information is voluntary. I do not need to sign this form, in order to assure treatment or
I can cancel this authorization at any time by writing to the Health Information Services Dept. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled.
Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws.
This authorization will EXPIRE ONE YEAR FROM THE DATE SIGNED BELOW, unless another date is entered here:
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Signature of Patient/Legally Authorized
Signature of Patient or Legally Responsible Party (relationship to patient, if not patient)
*
Signature of Minor Patient if release pertains to (Releasing Sensitive Information - IMPORTANT)
*
Date (XX/XX/XXXX)
*
Date (XX/XX/XXXX)
*
Submit
Home
Locations
Garfield County Hospital District
Pomeroy Medical Clinic
Providers
Services
Diagnostic Imaging
Emergency
Inpatient Services
Kidney Services and Dialysis
Lab Diagnostics
Outpatient IV Treatments
Outpatient Baths
Primary Care
Telehealth
Therapy Services
Transitional Care
Wound Care
Patient & Visitors
Billing
Medical Records Request
Patient Information
Patients Rights and Responsibilities
Patient Testimonials
Pricing Transparency
About
Board of Commissioners
Contact
COVID-19
Employment Opportunities
Giving
Imaging Suite
Mission/Vision
News Room
Public Records
G-TW2FZVG7KP
