FILE #__________
ECU PASS Clinic Initial Application & Contact Information
Patient’s Full Name____________________________ Birthdate________Age_____Gender____________
Local
Address________________________________ City_____________________ State____ Zip Code______
Permanent
Address________________________________ City_____________________ State____ Zip Code______
Preferred Phone _________________________ Alternate Phone Number ________________________
Are you (or Partner) ____ ECU Student _____ ECU Staff/Faculty
Adult Patient or Responsible Adult for Billing
____ Neither (Community)
Spouse/Partner (if applicable)
Self or Relationship to Patient_________________
Relationship to Patient _________________________
Name_______________________Gender_______
Name____________________________Gender_____
Date of Birth________________Age____________
Date of Birth___________________Age__________
Education (Years Completed)__________________
Education (Years Completed)___________________
Occupation________________________________
Employment Status (Check One):
(1) Unemployed
(2) Part-time
(3) Full-time
(4) Retired
(5) Disabled
Occupation _________________________________
Employment Status (Check One):
(1) Unemployed
(2) Part-time
(3) Full-time
(4) Retired
(5) Disabled
Employer__________________________________
Employer___________________________________
Military Service Member: Yes _____ No _____
Military Service Member: Yes _____ No _____
Branch: __________________
Branch: __________________
Years of service (#): _____
Years of service (#): _____
Dates of service (approximate): ________-________
Dates of service (approximate): ________-________
Children’s/Dependent’s Names
Shared/Other
Custody (circle)
1._________________________________ S/O
Birthdate
Gender
Age
Grade
2. _________________________________
S/O
________ ______ ______ ________________
3. _________________________________
S/O
________ ______ ______ ________________
4. _________________________________
S/O
________ ______ ______ ________________
________ ______ ______ ________________
(USE BACK TO LIST ADDITIONAL CHILDREN)
Patient’s Demographic Information
Patient’s Ethnicity: (1) European-American (Caucasian) (2) African-American (3) Hispanic-American (4) NativeAmerican (5) Asian-American (6) Multi-Racial (7) International __________________
Is patient’s primary language English? Yes _____ No ____ If no, list primary language: ________________
Rev. ME/TC 4/2013
FILE #__________
Patient’s Relationship Status: (Check one) (1) Child (N/A) (2) Single (3) Married (4) Divorced (5) Separated
(6)Widowed (7) Further explanation (e.g., cohabiting)_____________________________________________
Patient’s Sexual Orientation: (Check one) (1) Child (N/A) (2) Heterosexual (3) Lesbian (4) Gay (45) Bisexual
(6) Questioning (7) Further explanation ________________________________________________________
Patient’s Religious Affiliation Yes_____ No _____
Sect/ Denomination ____________________________
CONTACT PREFERENCES
OK to leave Phone Message from the ECU PASS Clinic?
Ok to Contact via email for scheduling only?
Yes____
Yes____
NO_____
NO_____ Email Address________________
Other contact preferences?_______________________________________________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name ____________________________________ Relationship to patient ___________________________
Address ________________________________________________________________________________
(Street, Apt. #))
(City)
(State)
(Zip Code)
Telephone #: Daytime_______________________________ Evening______________________________
Thank You
Rev. ME/TC 4/2013