Orange County, California - Health Care Agency



64204857112000Client LabelCounty of Orange, CaliforniaHealth Care Agency17th Street Testing and TreatmentALL INFORMATION ON THIS FORM IS CONFIDENTIALCONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10PATIENT REGISTRATION FORMLast NameFirst NameMiddle NameDate of Birth (MMGender FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Transgender M to F FORMCHECKBOX Transgender F to M Street AddressCityZip CodeTelephone Number( )EmailPlace of BirthMother’s Maiden NameHispanic FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownEthnicity FORMCHECKBOX Aleut FORMCHECKBOX Algerian FORMCHECKBOX American Indian FORMCHECKBOX Black/African American FORMCHECKBOX Cambodian FORMCHECKBOX Caucasian/White FORMCHECKBOX Chinese FORMCHECKBOX Cuban FORMCHECKBOX Egyptian FORMCHECKBOX Eskimo FORMCHECKBOX Filipino FORMCHECKBOX Guamanian FORMCHECKBOX Hawaiian Native FORMCHECKBOX Hispanic-Other FORMCHECKBOX Indian (Asian) FORMCHECKBOX Iranian FORMCHECKBOX Iraqi FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Laotian FORMCHECKBOX Lebanese FORMCHECKBOX Mexican FORMCHECKBOX Native American /American Indian FORMCHECKBOX Pacific Islander FORMCHECKBOX Palestinian FORMCHECKBOX Puerto Rican FORMCHECKBOX Samoan FORMCHECKBOX Somalian FORMCHECKBOX South/Central American FORMCHECKBOX Spanish FORMCHECKBOX Thai FORMCHECKBOX Vietnamese FORMCHECKBOX Withheld FORMCHECKBOX Unknown FORMCHECKBOX Other____________Race FORMCHECKBOX Alaskan Native FORMCHECKBOX American Indian FORMCHECKBOX Asian FORMCHECKBOX Black FORMCHECKBOX Pacific Islander FORMCHECKBOX White FORMCHECKBOX Unknown FORMCHECKBOX Other____________Primary Language FORMCHECKBOX Am. Sign Language FORMCHECKBOX Arabic FORMCHECKBOX Armenian FORMCHECKBOX Cambodian FORMCHECKBOX Cantonese FORMCHECKBOX English FORMCHECKBOX Farsi FORMCHECKBOX French FORMCHECKBOX German FORMCHECKBOX Greek FORMCHECKBOX Hebrew FORMCHECKBOX Hindi FORMCHECKBOX Hmong FORMCHECKBOX Italian FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Lao FORMCHECKBOX Mandarin FORMCHECKBOX Mien FORMCHECKBOX Persian FORMCHECKBOX Polish FORMCHECKBOX Portuguese FORMCHECKBOX Romanian FORMCHECKBOX Russian FORMCHECKBOX Samoan FORMCHECKBOX Spanish FORMCHECKBOX Tagalog FORMCHECKBOX Thai FORMCHECKBOX Turkish FORMCHECKBOX Vietnamese FORMCHECKBOX Other____________Emergency Contact Last NameFirst NameTelephone ( )I herby give permission to County of Orange Health Care Agency physicians, nurses, medical practitioners and personnel in medical training to perform examinations, tests and treatments upon myself as recommended and explained to me by public health personnel.Client SignatureDate Client Label3273425-1460500County of Orange, CaliforniaHealth Care Agency17th Street Testing and TreatmentALL INFORMATION ON THIS FORM IS CONFIDENTIALCONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10PATIENT REGISTRATION FORMIn order for us to better serve you, please check the reason(s) you came in today. It is important to be honest and complete with these answers so that we can insure that you receive the highest quality of service. FORMCHECKBOX First STD Visit FORMCHECKBOX Treatment FORMCHECKBOX Results FORMCHECKBOX Hepatitis Vaccine FORMCHECKBOX STD Check-up FORMCHECKBOX Counselor/Questions FORMCHECKBOX My partner/I had contact with STD (Sexually Transmitted Disease) FORMCHECKBOX Notified by a Public Health Representative FORMCHECKBOX Notified by ____________________ to come to clinic FORMCHECKBOX I received a telephone call or letter to come in to clinic Are you having any of the following symptoms today (check all that apply)? FORMCHECKBOX No, I have no symptoms today. I just want to get checked. FORMCHECKBOX Abdominal pain FORMCHECKBOX Sore throat/Swollen glands FORMCHECKBOX Bleeding between periods FORMCHECKBOX Sore/Lesion FORMCHECKBOX Burning with urination FORMCHECKBOX Testicular pain FORMCHECKBOX Itching FORMCHECKBOX Vaginal discharge/Pain FORMCHECKBOX Rash FORMCHECKBOX Vaginal odor FORMCHECKBOX Rectal discharge/Pain FORMCHECKBOX Warts/Bumps ................
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