New Patient Intake Questionnaire

New Patient Intake Questionnaire
Approximate completion time ~ 15 minutes

Please fill out this intake form so our clinical and administrative team can begin to assess your treatment protocol.

We typically respond to this form within 24 hours of receiving it.

We look forward to supporting you!
What kind of support are you looking for?

I feel healthy and want to keep it that way by building/maintaining my wellbeing I'm a busy professional and want to build/maintain my physical and mental resilience I want to boost my athletic performance I feel achy and tired a lot I'm struggling with depression and/or anxiety I want help with drug/alcohol addiction recovery and withdrawal management I experience chronic pain and am wanting relief I'm struggling with mood swings and general motivation
In your own words, please briefly describe why you are seeking treatment? What are you struggling with? What are you hoping these treatments will change?
What is your timeline/sense of urgency?

As soon as possible (Critical/Emergent) Some time in the next week (Urgent) Some time in the next 2 weeks (Somewhat Urgent) Some time this month (Soon) Some time in the next 3 months (Not Urgent)
How did you find out about CIT Clinics?

I was referred by a friend/family member I was referred by my mental health professional (psychiatrist, therapist, social worker, etc.) I was referred by my doctor (primary care physician, specialist, etc.) I did a Google search I used a search engine other than Google Apple Maps LinkedIn Yelp Nextdoor.com Veterans Administration I saw an online advertisement/link Other
Name of person referring you
Your Contact Information
Email *
example@example.com
Name *

First Name Last Name
Mobile Phone Number *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Personal Information
Date of Birth *

Month Day Year
Date
Height
Weight
Gender

Female Male
Pregnancy/Menstruation Info
Are you pregnant?

Yes No
Are you breastfeeding?

Yes No
When was your last menstrual period?

Month Day Year
Date
Medical Conditions
Medical conditions

Abdominal pain Abnormal bleeding/clotting disorder Acid reflux Anemia Asthma Bone/joint disorders Chest pains/angina Chronic pain Cognitive challenges Congestive heart failure COPD/Emphysema/Chronic Bronchitis Dementia Diabetes Difficulty exercising Dizziness/fainting Gynecologic issues Headaches Heart disease Irregular heart rhythm Kidney problems Liver problems Muscle disorders Nausea/vomiting Numbness/tingling GI conditions Pulmonary hypertension Seizures Stroke/TIA Thyroid issues Unsteady gait Using home oxygen Visions/voices Other
Please list any other medical conditions not noted above and/or explanations of the conditions above that you feel would be helpful for us to know.
What prescription medications are you currently taking?
What over-the-counter mediations, supplements, herbs, etc. are you currently taking?
Please list 1) names, 2) conditions being used for, 3) dose 4) frequency of use
Surgeries & Anesthesia
Previous surgeries
please list 1) the type of surgery, 2) surgery date, 3) the underlying condition being treated and 4) outcome/success
Have you or any direct family members ever had a serious adverse reaction to anesthesia?

Yes No
What was the adverse reaction and to whom did it happen?
Allergies
Do you have any allergies?

Yes No
What allergies do you have?
List 1) known allergies and 2) their severity
Tobacco
Do you use any tobacco products?

Yes No

Other tobacco products?
List 1) type of products and 2) frequency of use
Alcohol
Do you drink alcohol?

Yes No

Recreational Drugs & Psychedelics
Have you ever used recreational drugs and/or psychedelics

Yes No

List the dates of use for any of the compounds/drugs listed above. Please note, for your safety it is important that we are aware of this information so we may prevent/manage any possible contraindications. For example (but not limited to): Adderall, Valium, Ativan, etc.
Please list 1) name of substance, 2) date last taken
Other recreational drugs & psychedelics not listed above?
Please list 1) name of substance, 2) date last taken
Chronic Pain
Are you currently experiencing chronic pain?

Yes No
Do you currently have a chronic pain specialist/healthcare provider?

Yes No
Chronic pain specialist/provider name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Chronic pain specialist phone number
Chronic pain specialist/provider email
example@example.com
Primary Care Provider
Do you currently have a primary care provider?

Yes No
Primary care provider name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Primary care provider phone number
Primary care provider email
example@example.com
Mental Health Conditions

Are you experiencing any of the following?

	None	Some	Often	Chronic
Anxiety
Depression
PTSD

Have you ever received a formal diagnosis from a psychiatric provider?

Yes No
What is/was the official diagnosis?

Depression Anxiety PTSD Other
Mental Health Provider
Mental health provider type

Psychiatrist Therapist/Psychologist Social Worker Other
Psychiatrist name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Psychiatrist phone number
Psychiatrist email
example@example.com
Therapist/Psychologist name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Therapist/Psychologist phone number
Therapist/Psychologist email
example@example.com
Psychiatric Medications
Are you currently taking any prescription psychiatric medications?

Yes No
What psychiatric medications are you currently taking?

Antidepressants Antipsychotics Mood stabilizers Antianxiety agents Stimulants Other
List other psychiatric medications
please list 1) name of medication, 2) dose and 3) frequency of each medication you are taking.
Suicide
Have you ever attempted suicide?

Yes No
Are you currently suicidal?

Yes No
Addiction Treatment
Have you ever been treated for any addictions?

Yes No
When were you being treated for addiction?

Currently Last year Last 2- 5 years More than 5 years ago
Addiction program/counselor name
Addiction program/counselor phone number
Addiction program/counselor email
example@example.com
Health Insurance
Do you have health insurance?

Yes No
Health Insurance Provider Name
Health Insurance Plan/Type

HMO PPO EPO POS Other
In Case Of Emergency Contact (ICE)
ICE Name

First Name Last Name
Relationship to you

Spouse Partner Wife Husband Daughter Son Mother Father Friend Other Family Member Neighbor Work Colleague Other
Their Phone Number
Please enter a valid phone number.
Their Email
example@example.com
Summary Statement
If these treatments are successful, how are you hoping your life will change/improve? What are you hoping to be able to feel/do/experience that is currently unavailable to you? What are your hopes/wishes for the future?
Contact Type
Lead Status
Lead Source
Patient Attestation

By submitting this form, I certify that I have completed this Questionnaire to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges.I authorize a representative from CIT Clinics to contact me to discuss treatment options for my condition(s). I also understand that the staff of CIT Clinics may not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment. I also consent to receiving emails from CIT Clinics for marketing purposes and I may opt out at anytime in the future by unsubscribing from CIT Clinic's marketing list.
Should be Empty:

	Not currently	Yearly	Monthly	Weekly	Daily
Cigarettes
Cigars/Cigarillos
E-cigarettes
Chewing tobacco

	None	Daily	Weekly	Monthly
Beer
Wine
Hard alcohol/liquor

	Never	Daily	This past week	This past month	This past year
Marijuana/Cannabis
MDMA/Molly
Psilocybin/Mushrooms
LSD/Acid
Ayahuasca
DMT/5-MeO-DMT
Cocaine
Methamphetamine
Heroin/Opium/Opioids
Ketamine
GHB

New Patient Intake Questionnaire

Your Contact Information

Personal Information

Pregnancy/Menstruation Info

Medical Conditions

Surgeries & Anesthesia

Allergies

Tobacco

Alcohol

Recreational Drugs & Psychedelics

Chronic Pain

Primary Care Provider

Mental Health Conditions

Mental Health Provider

Psychiatric Medications

Suicide

Addiction Treatment

Health Insurance

In Case Of Emergency Contact (ICE)

Summary Statement

Patient Attestation