Patient Profile

__________________ Primary Care Center

_____ Number of patients seen in 1 year

Age ranges of the patients

_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Patient age ranges by sex

Females
_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Males
_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Number of prenatal patients ________ in 1 year

Cultural Diversity

We serve _______ different ethnic groups that speak the following languages:
________________________________________________________________
_______ percent of these patients are recent (within 5 years) immigrants to the United States.

Income and Occupation of Clinic Users

We serve ______ users who are migrant and seasonal farm workers. They are usually here during the months of ______ through ______. Other occupations of our clinic users that may affect their health are ___________________________________________________________.
The proportion of persons/families below the poverty level using the clinic is ______ percent of the total patient load. Of the total user group, ______ are homeless.

User Health Problems

The most frequent complaint seen for children in the clinic is ______________________; the next three are ___________________, ________________, and _______________. We usually see adolescents for __________________________.

We treated ______ persons with alcohol and other drug abuse last year. This figure includes ______ pregnant women. We serve ______ patients who are HIV positive; this is a ______ percent increase (decrease) over the previous year. We served ______ pregnant adolescents last year. This is a ______ percent increase (or a ______ percent decrease) over the previous year.

Community Profile

__________________ Primary Care Center

_____ Number of residents seen in 1 year

Age ranges of the residents in the year ________

_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Resident age ranges by sex

Females
_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Males
_____ 0 to 1 year
_____ > 1 year to 5 years
_____ > 5 years to 10 years
_____ > 10 years to 15 years
_____ > 15 years to 25 years
_____ > 25 years to 45 years
_____ > 45 years to 65 years
_____ > 65 years

Number of women of childbearing age (15 to 45) was ______ in the year ______.

Cultural Diversity

The community has ______ different ethnic groups, that speak the following languages:____________________________________________________________; ______ percent of these patients are recent (within 5 years) immigrants to the United States. The recent immigrants are primarily from ______________________________ _____________________________________________________________________.

Income and Occupation of Community Residents

The community of _______________________ includes ______ residents who are migrant and seasonal farm workers. They are usually here during the months of _______________ through _______________. Other major occupations in the community that may affect worker health are ___________________________________________________________.The unemployment rate is ______ percent, which is ______ percentage points higher (or ______ percentage points lower) than at this time last year.

The proportion of persons/families below the poverty level in the community is ______ percent of the total population. It is estimated that there are ______ persons who are homeless in the community; ______ percent of these are families with children.

Major Community Health Problems

The major causes of mortality in the community are _________________, _____________________, and _____________________. For children and adolescents, the major causes are ______________________, ________________________, and ________________________.