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New Patient Registration

Patient Registration PDF
Health History PDF

Please click the link above to download the form If you prefer to print the form and fill it out. You may bring it to your first appointment or submit it via the contact information below:

Fax

ATTN: Scheduling
(541) 756-6234

Mail

Waterfall Clinic
Attn: Scheduling
1890 Waite St.
North Bend OR, 97459

Patient Registration Form

Please fill out the form below to send us your registration information. Fields marked with an asterisk (*) are required.

Waterfall Community Health Center is a Federally Qualified Health Center and receives federal funding pursuant to Section 330 of the Public Health Service Act. We are required to collect information about age, gender, race, sexual orientation, income, and family size for statistical purposes only. No individual information is submitted.

Health History Form

Please fill out the following form about your and your family's medical history.

Health History Questionnaire
Name
Name
First
Last
Gender

Personal Health History

Please check all that apply

Patient's Medication

Including prescriptions, herbals, and over the counter drugs such as VITAMINS & INHALERS

List of Patient's Allergies

List all allergies to medications, foods, contrast, and dyes.

Medical Problems

Mark ALL medical problems that other Doctors or care providers have diagnosed you with.

Medical Issues

Surgeries

(tonsils, appendix, C-section, joints, tubal ligation, fracture repair)
Have you ever had a blood transfusion (received blood)?

Health Habits and Safety

Please check all that apply

Family Health History

Include the age at death if deceased

Siblings

Please indicate Male or Female
Sibling
Gender

Children

Please indicate Male or Female
Children
Gender

Family History

Please check if family member had the listed problem.

Activities of Daily Living and Concerns

Please check all that apply and add comments if needed

Symptoms

Please CHECK ALL items which apply to your health during the PAST 6 MONTHS.

Women Only