Registration Form (Step 2) - CHI EveryYou Health Form

Patient Registration

Health Questionnaires

Consent Forms

Confirmation

"*" indicates required fields

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UniqueID

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Have you visited CHI before?*

Yes

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Mental Health

Therapy

Psychiatry

Substance Use Disorder Treatment

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Sexual Health

PrEP for HIV Prevention

General Sexual Health

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PrEP

PrEP for HIV Prevention

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Primary Care

Primary Care: Support for everyday needs

Pediatrics: Care for children 0‑17 years old

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GET YOUR LABS DONE

Quest Diagnostics

CHI Health Center

Coming Soon - At-home test

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ProviderName

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Time

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Contact Information

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Patient Name*

First Name * MI * Last Name *

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Date of Birth*

MM slash DD slash YYYY

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Marital Status*

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Address*

Address * Apt/Suite City * State * Zip Code *

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Email*

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Cell Phone*

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Home Phone*

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Work Phone*

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Personal Details

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Race*

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Ethnicity*

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Gender Identity*

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Sexual Orientation*

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Preferred Language*

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IF “OTHER”, SPECIFY LANGUAGE*

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COMMUNICATION/SPECIAL NEEDS*

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ARE YOU A VETERAN?*

Yes

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Emergency Notification

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CONTACT NAME*

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RELATIONSHIP TO PATIENT*

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CELL PHONE*

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OTHER PHONE

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Phone Type

Home

Work

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CONTACT NAME*

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RELATIONSHIP TO PATIENT*

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CELL PHONE*

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OTHER PHONE

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Phone Type

Home

Work

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Pharmacy

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CHOOSE YOUR PHARMACY*

Local Pharmacy
Balaji Pharmacy
1726 Mermaid Ave(map )
Brooklyn NY 11224
Phone: (718) 996-9000
Free delivery within 52-mile radius

Mail-Order
Express Scripts Pharmacy
Phone: (800) 282-2881
24 hours a day, 7 days a week
Free home delivery

Choose another pharmacy

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Pharmacy Name*

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Pharmacy Phone*

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Address*

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Zip Code*

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Financially Responsible Party

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Same Patient Information

Same as patient information

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Patient Name*

First Name * MI * Last Name *

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Date of Birth*

MM slash DD slash YYYY

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Marital Status*

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Address*

Street Address Address Line 2 City State ZIP Code

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Email*

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Cell Phone*

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Home Phone*

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Work Phone*

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RELATIONSHIP TO PATIENT*

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EMPLOYER

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HOUSING*

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ANNUAL HOUSEHOLD INCOME*

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Identification and Insurance Information

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Upload Front of Card

Max. file size: 10 MB.

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Upload Back of Card

Max. file size: 10 MB.

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Patient Have No Insurance

Patient does not have insurance.

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PRIMARY INSURANCE PROVIDER*

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RELATIONSHIP TO SUBSCRIBER*

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MEMBER ID*

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GROUP ID

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SUBSCRIBER NAME

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DATE OF BIRTH

MM slash DD slash YYYY

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Upload Front of Card

Max. file size: 10 MB.

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Upload Back of Card

Max. file size: 10 MB.

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SECONDARY INSURANCE PROVIDER*

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RELATIONSHIP TO SUBSCRIBER*

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MEMBER ID*

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GROUP ID

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SUBSCRIBER NAME

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DATE OF BIRTH

MM slash DD slash YYYY

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Upload Front of Card

Max. file size: 10 MB.

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Upload Back of Card

Max. file size: 10 MB.

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Patient Health Questionnaire

Over the last two weeks, how often have you been bothered by any of the following problems?

Not at all

Several days

Over half the day

Nearly every day

1. Little interest or pleasure in doing things

Not at all

Several days

Over half the day

Nearly every day

2. Feeling down, depressed, or hopeless

Not at all

Several days

Over half the day

Nearly every day

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PHQ Score

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

Over half the day

Nearly every day

4. Feeling tired or having little energy

Not at all

Several days

Over half the day

Nearly every day

5. Poor appetite or overeating

Not at all

Several days

Over half the day

Nearly every day

6. Feeling bad about yourself, that you are a failure, or have let yourself or family down

Not at all

Several days

Over half the day

Nearly every day

7. Trouble concentrating on things such as reading the news or watching television

Not at all

Several days

Over half the day

Nearly every day

8. Moving or speaking slowly that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around more than usual

Not at all

Several days

Over half the day

Nearly every day

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all

Several days

Over half the day

Nearly every day

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not at all difficult

Slightly difficult

Moderately difficult

Very difficult

Extremely difficult

Sexual Health Questionnaire

Please check off your answers for the following questions (optional):

1. In the past year, have you been sexually active?

Yes

In the past 6 months, have you been sexually active?

Yes

Have you been sexually active without a condom?

Yes

Have you had multiple partners in the past 6 months?

Yes

2. Have you been diagnosed with any sexually transmitted infections (STI) in the past 6 months?

Yes

If yes, which ones?

3. Have any of your partners tested positive for an STI in the past 6 months?

Yes

If yes, which ones?

4. Have you been tested for HIV in the past 6 months?

Yes

5. Have you heard of pre-exposure prophylaxis (PrEP)?

Yes

Have you ever taken of PrEP?

Yes

6. Have you heard of post-exposure prophylaxis (PEP)?

Yes

Have you ever taken PEP?

Yes

7. Are you interested in learning more about PrEP, PEP, and STI prevention?

Yes