New Patient Intake

New Patient Intake

Please complete this health history questionnaire to the best of your abilities. Dr Alexis Alexandridis will review your responses. Your Protected Health Information is secure on this intake form.
Personal Information

Contact Info, Demographics, Emergency Contacts
Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *

Female Male Non-binary
Email *
example@example.com
Phone Number *

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation
Employer
Insurance Information *
Plan Name
ID number
Group Number
Secondary Insurance Information
Plan Name
ID number
Group Number
Or, upload a copy of your insurance cards, front and back

Browse Files
A smartphone snapshot works fine! Cancel of
Emergency Contact Name *

First Name Last Name
Relationship
Emergency Contact Phone Number

Area Code Phone Number
Primary Care Physician

First Name Last Name
Pharmacy
Your Health Information

Past Medical and Surgical History
Why are you seeing Dr Alexis today? *
Body Measurements *
Please list your Allergies *
Have you ever had or are you being treated for: *
Any other medical conditions?
Please list any Operations you have had.
Please list your Current Medications, including dosage. *
Have you had a colonoscopy before?
If yes, when?
Results?
Women, are you?

Pre-menopausal Peri-menopausal Post-menopausal, natural Post-menopausal, surgical
Age at Menarche (first period)
Age at Menopause
Number of Pregnancies
Number of Births
Age at First Birth

Your Health Habits

Social History
Do you use Alcohol? *
If yes, how many drinks per WEEK
Do you use Tobacco? *
If yes, how many per DAY
Do you use Marijuana? *
Additional Comments

Thank you!

Please take a moment to review the policies linked below and indicate your acceptance. The link will open a new window and the documents are available for review. Your signature indicates that you have read the policies and accept the terms.
Signature *

Clear
Today's Date *

Month Day Year
Date
Please verify that you are human! *
Should be Empty:

New Patient Intake

Personal Information

Your Health Information

Your Health Habits

Your Family Medical History

Review of Systems

Thank you!