• Patient Information

  • What is your birthday?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Behavioral Health Integration

    We like to provide holistic care for our patients, and because pain and loss of function can affect other aspects of your life, we ask that you fill out this brief screening questionnaire.  

  • GAD

  • Over the last 2 weeks, how often have you been bothered by the following problems?*
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  • Some techniques shown to be helpful in managing anxiety are deep breathing exercises, progressive muscle relaxation, and meditation. Would you like referral to a counselor or psychiatrist?
  • Do you want to be referred to a:

  • PHQ

  • Over the last 2 weeks, how often have you been bothered by the following problems?*
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  • Exercise has been shown to be as effective as medications for mild to moderate depression. Would you like referral to a counselor or psychiatrist?
  • Do you want to be referred to a:
  • Gender*
  • Age between 16-45 years?*
  • Family History of Substance Abuse*
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  • Personal History of Substance Abuse*
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  • Personal History of Sexual Abuse*
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  • Personal History of Psychological Disease*
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  • Thank you for your responses

  • AUDIT

  • *
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  • Rows
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  • Are you interested in decreasing your alcohol use?*
  • Your health is important. Let us know if you would like assistance in the future.

  • Body Mass Index (BMI) Calculator

  • Enter Weight:

    Enter Height:

  • Preferred Unit:*

  • LETS SEE YOUR WEIGHT STATUS

  • Would you like help with:*
  • Would you like help with:*
  • TOBACCO USE (Do you currently smoke?)*
  • Are you ready to quit?
    • Resources for quitting: 1-800-QUITNOW
    • Discuss with Dr. Patel about treatments to help with tobacco cessation
  • Your health is important. Let us know if you would like assistance in the future, as quitting is best for your long term health.
  • Do you know your blood pressure?
  • Should be Empty: