Behavioral Health Integration Follow Up

Patient Information
What's your name? *

First NameLast Name
What is your birthday?*
What's your birthday?*

MonthDayYear
Date
Has your address changed?*

YesNo
New Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your contact phone number changed?*

YesNo
New Phone Number*
Please enter a valid phone number.
Has your insurance information changed?*

YesNo
New Primary Insurance Plan Name:*
New Primary Insurance ID Number:*
Group Number:
Patient’s Relationship to Policy Holder:*
Insurance ID card (Front):
Insurance ID card (Back):
Please upload or take a photo of your Insurance ID card (Front):

Cancelof
Please upload or take a photo of your Insurance ID card (Back):

Cancelof
Do you have a secondary insurance*

YesNo
Secondary Insurance Plan Name:*
Secondary Insurance ID Number:*
Group Number:
Patient’s Relationship to Policy Holder:*
Insurance ID card (Front):
Insurance ID card (Back):
Please upload or take a photo of your Insurance ID card (Front):

Cancelof
Please upload or take a photo of your Insurance ID card (Back):

Cancelof

Body Mass Index (BMI) Calculator
Enter Weight:

Enter Height:
LETS SEE YOUR WEIGHT STATUS
You Are:
Would you like help with:*

DietingExercise ProgramReferral for advanced treatmentNo, at the moment
Would you like help with:*

DietingExercise ProgramReferral for advanced treatment (Bariatrics)No, at the moment
Nutritionist
Physical Therapy
Bariatric surgeon
Empty when score is 0
Class Obesity

TOBACCO USE (Do you currently smoke?)*

YesNo
How many cigarettes per day do you use?
Are you ready to quit?

YesNo
- 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.
Quit
no quit

Do you know your blood pressure?

YesNo
Systolic (high number):
Diastolic (low number):
blood pressure

Do you have any new medical conditions or allergies since your last visit that you would like us to know about?

YesNo
New medical conditions or allergies:

Do you have a history of palpitations, arrhythmias, heart failure or heart attack? Did you ever have a monitor of your heart that you wore? Do you have an implanted cardiac device?*

YesNo
Would you like to talk to a doctor in the clinic about this?*

YesNo
Thank you. We will schedule you with our providers.
Ok, let us know if we can be of service in the future.
Should be Empty: