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JFS Patient Navigator Program

Pre-Appointment Form
Top part will be filled out by JFS staff and forwarded to the Patient Navigator volunteer
Client Name: __________________________________ Date of birth: ________ Age:_____
Phone Number: _________________
Address: ______________________________
_______________________________________________________________________
Emergency Contact: ________________ Relationship_______________________
Phone #: ___________________
With whom should PN fill out this form? Client Caregiver Other__________
Medical Appointment:
Date of visit: __________________ Time of visit: __________________
Providers name: ___________________________ Office phone #:_________________
Office address: ___________________________________________________________
Has client seen this provider before? Y N
How long does client anticipate this visit lasting?____________________
Will a caregiver accompany the client to the visit? Y N
How will client be getting to this doctors appointment?
Patient Navigator
Driving self
ITN

If yes, does the client have a handicap parking tag? Y

Taxi

Other________

If yes, has the ride been scheduled? Y N Pick up time:_____

Notes:

___________________________________________________________________________________
To be filled out by Patient Navigator by phone or in-person with client before scheduled appointment.

Name of Patient Navigator completing this form:

_______________________________________ Date: _______________
Please remind client to bring to their medical/procedure appointment:
Insurance card
List of medications they are currently taking
List of providers
IF client has DIABETES: glucose tablets, snack or whatever they use to manage the condition
IF client is disabled AND the PN is driving: handicap parking tag
___Client must sign on page 3.
___Return this completed form to JFS.

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1. Type of visit: Routine check-up New problem
Follow-up
Procedure
Other:_____________
1a. Have you been instructed to bring any particular equipment or records with you (e.g.,
glucometer, home blood pressure readings, etc.)?
Y
N
If yes, what? ___________________________
2. What are the reasons for this appointment?
a. __________________________________________________
b. __________________________________________________
3. Any changes in your life you want the doctor/nurse to be aware of?
________________________________________________________
________________________________________________________
4. What symptoms do you want the Provider to know about?
Symptom Description

Is this symptom interfering with your

ability to do things you enjoy?

5.
6.
5. What questions do you have for the doctor about your
health conditions, symptoms, or treatment?

a) __________________________________________
b) __________________________________________
c) __________________________________________
6. Is there any specific help that you would like from me, your Patient Navigator,
during this visit?
_______________________________________________________
_______________________________________________________
___Client must sign on page 3.
___Return this completed form to JFS.

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7.Would you like your Patient Navigator to:
Remain in the examination room while you undress?
Remain in the examination room with you during the physical exam?
Please inform the client that they should let you know if they would like you to leave the examination
room at any point during the appointment.
I have received a copy of JFS Client Bill of Rights and Responsibilities and

understand what my rights and responsibilities are.

Client signature:__________________________ ____________________
Print Name:__________________________________________________
Patient Navigator Signature: ______________________________________
Date: _____________

Pre-Appointment Phone Notes:_____________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Length of Phone Call__________________________

___Client must sign on page 3.

___Return this completed form to JFS.