Patient Identification Form

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1 Identification Information Weill Cornell Community Clinic Patient Identification Form Today s Date: / / Name: (last) (first) (middle) DOB (mm/dd/yyyy): / / Current Address: (street) (city) (state) (zip) Current Phone Number: Address: Mother s Name: Father s Name: Emergency contact / alternative way to reach you: Allergies: Medications you are taking: The WCCC distributes a free quarterly WCCC e-newsletter on important health topics and affordable access to health care services, written and distributed by Weill Cornell medical students. Would you like us to send this newsletter to your address? Yes / No *Please note: All services provided by the WCCC are free of charge to you. However, since all WCCC patients are registered in the New York Presbyterian Hospital system, occasionally a bill is mistakenly generated for one of our patients. If you receive a bill, we ask that you contact the clinic by phone or so we can quickly remedy the situation. Thank you for your understanding as we seek a permanent solution to this problem. Last updated on 12/17/07 by ADC Page 1 of 1

2 Patient Questionnaire Date Thank you for filling this survey out. We will use the information that you provide us to understand the population of our clinic. All information that you give us through these questions will be kept completely confidential. GENERAL AND HEALTH 1. How did you find out about WCCC?! Website! Friend! Flyer 2. What is your gender:! Male! Female 3. Year of birth? 4. If you were not born in the US, how long have you lived in this country?! Less than 6 months! At least 6 months! Between 1 and 2 years! Between 2 and 4 years! 4 or more years! I was born in the US 5. When was your last physical exam? 6. Have you ever been tested for HIV/AIDS? If yes, how long ago? 7. When was your last blood pressure measurement taken? 8. When was your last blood test for cholesterol? 9. When was your last tuberculosis skin test (PPD)? Last updated on 3/25/2010 Page 1 of 5

3 10. When was your last colonoscopy? 11. (Men Only) When was your last prostate exam? 12. When was your last eye exam? 13. (Women only) Have you ever had a mammogram? How long ago? 14. (Women only) Have you ever had a pap smear How long ago? 15. If you take or have taken any prescription medications in the last year, how did you pay for those medications? Select all that apply.! Out of pocket! Private insurance! Government insurance! Doctor s samples! Free through program 16. On average how many times a week do you exercise for at least 20 minutes each time? (e.g. walking and gardening)! None! Less than once a week! Once a week! Twice a week! Three times a week! More than 3 times a week 17. What is the biggest challenge to exercising regularly? Please choose one.! No place to go! Not safe! Weigh too much! No time/too busy! I don t like exercising! Health clubs are too expensive! There are no health clubs in my neighborhood 18. Do you speak English at home? If no, what is your primary language? 19. What other languages are you fluent in? 20. a. Please describe your citizenship.! US citizen! Resident alien! Non-US citizen Last updated on 3/25/2010 Page 2 of 5

4 b. How would you describe your primary ethnicity?! Hispanic/Latino! Not Hispanic/Latino c. How would you describe your primary racial background?! American Indian or Alaskan Native! Asian! Black or African American! Native Hawaiian or Other Pacific Islander! White 21. Have you designated a healthcare proxy? A healthcare proxy is someone legally documented to make health care decisions for you in the event you are incapacitated and unable to make those decisions yourself. If yes, who is your healthcare proxy? (Please indicate the relation to you, e.g. friend or family member). 22. Have you filled out a living will? A living will is a legal document that indicates what healthcare measures you want undertaken in the event that you are incapacitated and unable to make those decisions. HOUSEHOLD AND EMPLOYMENT 23. What is your zip code? 24. What is your marital status?! Single/never married! Married! Divorced! Widowed! Separated! Domestic Partner 25. What is the highest level of education you ve completed? Please choose one.! Less than high school! Some high school! High school graduate or GED! Technical/trade school! Some college! College graduate! Graduate School 26. Please describe your household situation. Please choose one.! Rent! Own! Public housing! Shelter! Group or transitional home! Homeless 27. Including yourself, what is the number of people in your household: Who are under 18? Between the ages of 18-64? Older than 65? 28. Are you currently? Please choose one.! Employed full-time for wages! Employed part-time for wages! Self-employed! Out of work for more than a year! Out of work for less than a year! A homemaker! A student! Retired! Unable to work 29. If you are employed, what is your field of work? Please choose one.! Business! Government/public! Healthcare! Hospitality/Restaurant/Service! Information technology! Manufacturing! Military! Non-profit! Retail! Telecommunications! Legal Last updated on 3/25/2010 Page 3 of 5

5 30. If you are employed, how long have you been in that position?! <1 year to 1 year! 2 years! 3 years! 4 years! more than 4 years 31. If you are employed, how big is the company at which you work?! Self-employed! Less than 25 employees! Less than 50 employees! Less than 100 employees! 100 or more employees 32. How many jobs have you had in the past year?! None! One! Two! Three! Four! More than four 33. If you are unemployed, please specify your current status:! Seeking full time employment.! Seeking part-time employment.! Not seeking employment. 34. What is your total annual household income from all sources?! $0 - $10,000! $10,001 - $20,000! $20,001 - $30,000! $30,001 - $50,000! Over $50, Are you receiving any type of government assistance? If so, please specify ALL:! Welfare! Medicaid! Medicare! Disability! Social Security! Food Stamps! WIC HEALTH ACCESS 36. How did you hear about our clinic? Please choose one.! Community Based Organization Please list which one:! Internet! Word of mouth by family/friends! Health Fair! New York Presbyterian Hospital Referral! Referral from another free clinic! Other 37. Why did you decide to come to the Weill Cornell Community Clinic? Please choose one.! Proximity to Clinic! Free Care! Easy to get an appointment! Reputation in the community! Other 38. What is the hardest part of obtaining medical care? Please choose one.! Cost! Language Barrier! Finding a clinic with weekend hours! Finding a clinic open in the evening! Cultural or ethnic barriers! Other 39. Have you ever had health insurance? If yes, when did it end?! Less than 6 months ago! Between 6 months and 1 year ago! Between 1 and 2 years ago! Between 2 and 4 years ago! 4 or more years ago Last updated on 3/25/2010 Page 4 of 5

6 Why did your health insurance end? Please choose one.! Never Had it! Loss of Job! Graduated from school! Relocation/move! No insurance offered at current job! Insurance was too expensive 40. Was there a time in the past 12 months when you needed medical care, but could not get it? If yes, what was the main reason you did not get medical care? Please choose one.! Cost! Distance! Office wasn t open when I could get there! Too long a wait for an appointment! Too long a wait in the waiting room! No child care! No transportation! No access to people with disabilities! The medical provider didn t speak my language 43. Before coming to this clinic, where did you obtain healthcare? Check all that apply.! Private doctor s office! Another free medical clinic! Public hospital! Emergency room 44. What is your main source of health information? Please choose one.! TV! Radio! Internet! Book/Magazine! Friend/Family! Health-Education Teacher! Doctor or Non-Western Practitioner 41. Have you ever gone to the emergency room for care you felt you could not afford elsewhere? If so what was the most recent year? 42. Have you ever used a non-western medical treatment?! No! Yes (please specify) Last updated on 3/25/2010 Page 5 of 5

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