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  • New Patient Intake Form

    Patient Demographic Information
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • I need an interpreter:

  • If a treatment center client, please complete the following:

    Treatment Center Name:
    Treatment Center Phone:

  • Medical Insurance Information

  • Do you have a Secondary Insurance?*
  • Will you be using either:
  • Date of Injury*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Medical History Questionnaire

  • Chief Complaint - What Brings You Into Valley Medical? (Check all that apply)*

  • Past Medical History

    Check the following conditions/diseases that you have been diagnosed with/treated for in the past
  • Head/Eyes/Ears/Nose/Throat
  • Respiratory
  • Cardiovascular
  • Gastrointestinal
  • Genitourinary/Nephrology
  • Obstetric/Gynecological
  • Musculoskeletal
  • Rheumatologic
  • Neurological
  • Dermatological
  • Endocrine
  • Infectious Disease
  • Cancer/Blood Disorde5s
  • Psychiatric

  • Past Surgical History

    Please indicate any surgical procedures you have had in the past.
  • Abdominal Surgeries
  • Female Surgeries
  • Heart Surgery
  • Joint Surgery
  • Back / Spinal Surgeries
  • Other Common Surgeries

  • Family History

  • Family Medical History
  • Please check all appropriate diagnoses as they pertain to your biological family members
    Rows

  • Social History

  • Marital Status
  • Members of Household
  • Are you sexually active?
  • Who are you sexually active with?
  • Method of Protection:
  • Education
  • Occupation

  • Substance Use History

    If Applicable
  • Tobacco Use
  • Select the type of drug(s) you have tried/used in the past below
  • If you checked any of the drugs listed above, which options apply to you?
  • Addiction Treatment History (if applicable)

  • Pain Description

    If Applicable
  • Pain Description (check all that apply):
  • Please mark all of the following treatments you have used for pain relief and their effect:
    Rows

  • New Patient Intake Forms

    Please review the patient forms and sign to acknowledge
  • Patient Treatment Agreement
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Restricted Pharmacy Agreement

    I am seeking healthcare services from the physicians and providers at Valley Medical and Wellness (VMW) for the treatment of my condition. I acknowledge that I intend to provide all necessary releases for healthcare and to be accurate, complete, and truthful in disclosing my history and symptoms so that VMW may safely treat me for my condition. By signing below I understand and agree to the following:

    1. I give consent for VMW to share medical history with the pharmacy or pharmacies listed in this agreement so that my prescriptions may be monitored for my safety and continuity of care.

    2. I understand that obtaining prescription medication(s) through false representation is a crime, and that I will be reported to local law enforcement officials for attempting to fraudulently obtain prescription medications for non-therapeutic purposes.

    3. If I need to change pharmacies I will contact Valley Medical and Wellness’ clinic manager, choose a different pharmacy, and fill out a new Restricted Pharmacy Agreement with the clinic manager’s approval.

    4. I agree to only use one pharmacy, except when otherwise noted below, to get my medications(s). The name of my pharmacy is:

  • Format: (000) 000-0000.

  • I have read and understand what is required of me.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Please read the Notice of Privacy Practices.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: