New Patient Intake forms

This form will serve as a medical intake, which will allow us to check your eligibility to recieve your genetic cardiovascular test kit. All your information is confidential and secure. We follow all HIPAA laws and do not share any of your information with anyone outside our organization without prior wriiten consent.

Product

Comprehensive NEURO testComprehensive DIABETES testComprehensive Cancer testComprehensive Immunodeficiency test

Have you ever taken an at home-cheek swab for neurocognitive genetic testing or diabetes genetic testing before?

YESNO

Patient's Name*

First NameLast Name

Date of Birth*

Date

Medicare ID Number:

Name of your insurance carrier? If Medicare only, then type medicare.*

GENDER:*

MALEFEMALE

Ethnicity:*

What is your height and weight?

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Main Phone Number*

Second Phone Number

Please enter a valid phone number.

Email*

example@example.com

What time is best to reach you?*

Texting Consent (May we text reminders for your follow-up appointment?)*

YESNO

Primary Care Provider (first and last name)*

City and State*

PERSONAL History notes:*

PERSONAL Medical History: Have you been DIAGNOSED with any of the following conditions?*

	YES	NO	Age diagnosed?
Dementia
Vascular dementia
Cerebellar ataxia
ALS
Parkinson’s disease
Alzheimer’s disease
Frontotemporal lobe dementia
Lewy body dementia
NONE OF THE ABOVE

PERSONAL: Do you have any of the following SYMPTOMS?*

	YES	NO	Age when it started?
Depression
Anxiety
Fatigue
Insomnia
Sleep disorder
Tremor
Gait disturbance
Repeated falls
Amnesia
Hallucinations
Speech disturbance
Nervousness
Unhappiness
Violent behavior
Delusional disorders
autoinflammatory syndromes
Dysphagia
Unspecified abnormal involuntary movements
Dizziness and giddiness
Unspecified disturbances of smell and taste
Restlessness and agitation
Aphasia
Anorexia
Other problems related to life management difficulty
NONE OF THE ABOVE

Past Surgical history:

Marital Status*

Social History*

	Yes	No	Comments
Tobacco Usage History
Alcohol Usage History
Recreational Drug Usage History

Personal Allergies:

	On going	In the Past	Comments
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Pet allergies
other
NONE

Family History notes:*

had Dementia?*

YESNO

Which dementia?

	Living	Deceased	Family member
Vascular dementia
Frontotemporal lobe dementia
Lewy body dementia
Unsure

Cerebellar ataxia ?*

YESNO

Family member relationship / Living or Deceased age ?

ALS?*

YESNO

Family member relationship / Living or Deceased age ?

Parkinson’s disease?*

YESNO

Family member relationship / age diagnosed ?

Alzheimer’s disease?*

YESNO

Family member relationship / age diagnosed?

FAMILY Medical History: Anyone in your family been diagnosed with the following conditions?*

	YES	NO	Age diagnosed?
Diabetes Types 2
Prediabetes
High Cholesterol
High Blood Pressure
Sleep Apnea
Cancer
Coronary Artery Disease
blood disorders-anemia
lupus
rheumatoid arthritis
digestive problems
severe eczema
delayed growth and development
bone marrow failure or complications
nezelof syndrome
Di George’s syndrome
neutropenia
NONE OF THE ABOVE

How many prescriptions are you taking ?*

List of currently prescribed medications? (anti-depressant or anti-anxiety medications)*

HC - Atorvastatin (Lipitor®)Fluvastatin (Lescol®)Lovastatin (Mevacor®, Altoprev™)Pravastatin (Pravachol®)Rosuvastatin Calcium (Crestor®)Simvastatin (Zocor®) HBP - benazepril (Lotensin)captopril (Capoten)enalapril (Vasotec)fosinopril (Monopril)lisinopril (Prinivil, Zestril)moexipril (Univasc)perindopril (Aceon)quinapril (Accupril)

OK Great. That's all we needed to gather from you right now. We will turn your file in to our eligibility team to verify the information you provided to make sure this test is for you. If everything comes back good, they will give you a call. ***Eligibility also is dependent on patient’s insurance.***

Please feel free to call us if you have any questions

(888) 505 -3536.

By submitting I am giving express written consent authorizing the following: I understand that I will be contacted via Voice, SMS or email at the information provided regarding the following: confirming personal information, submitting or updating orders, and other healthcare benefits. I understand these calls or messages may be generated from an automated dialer or messaging system. I am not required to provide consent as a condition of requesting or receiving any products or services. I also understand that this offer does not qualify me for any prize or reward. I understand that I can opt out by replying STOP to the messages.*

I agree

Neurocognitive Evaluation

Patient Personal History:

FAMILY HISTORY:

Personal Medications