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New patient intake form
Please complete this medical questionnaire so that the doctor can best help you
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2
profileID
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3
Name
*
This field is required.
Please provide your full name. If you only have one name, then please enter it for the First & Last Name.
First Name
Last Name
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4
Sex
*
This field is required.
Male
Female
Other
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5
Phone Number
*
This field is required.
Provide the SAME phone number as your call back number.
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6
Email
*
This field is required.
Please provide your email address.
example@example.com
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7
Year Of Birth
*
This field is required.
Enter Year Of Birth In Format: 2022
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8
Occupation
Format: Student/ Employment/ Retired/, Benefits At Work (Company Name)
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9
Address
*
This field is required.
Enter Full Address.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Canada
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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10
Prescription Pickup Options
*
This field is required.
Our Medical Building Pharmacy (Free Home Delivery Available).
Other Pharmacy.
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11
Provide Name And / Or Fax Number Or Address Of Your Pharmacy
*
This field is required.
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12
Is It First Time Using Telemedicine At Our Facility?
First Time Using Telemedicine.
I Have Been To The Clinic As A Patient Before.
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13
How Did You Find Out About Our Clinic?
Referred By A Friend Or Family.
Referred By Your Family Doctor.
Referred By Your Pharmacist.
Signs Posted Outside (On Building).
Internet.
Text Message From Our Clinic.
Mailer.
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14
How Did You Find Us On The Internet?
Google Search.
Instagram.
Facebook.
Bing/Yahoo Search.
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15
Reason For Referral By Family Doctor
Referred To See A Specialist At Our Clinic.
Referred To X-ray/Ultrasound Dept.
Referred To Speak To Walk-In Clinic Doctor.
Other
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16
Height (In Feet/Inches)
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17
Weight (In Pounds)
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18
Do You Have Any Allergies To Medication?
*
This field is required.
YES
NO
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19
Please Provide More Details On Your Allergies.
FORMAT: Drug Name, [Type Of Reaction]
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20
Are You Currently Taking Any Medication(s)?
*
This field is required.
YES
NO
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21
Enter List Of Medication Name, Dosage And How Often You Take Them.
For Example, Metformin 500mg Twice A Day
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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22
Do you have any Heart Problems?
*
This field is required.
Heart issues include: High Cholesterol, High Blood Pressure, Heart Attacks, Angina, etc.
YES
NO
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23
Please provide more details on your Heart Problems.
Blood Pressure, Cholesterol, Angina/Heart Attack, Rhythm Problems, Other
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24
Do You Have Any Breathing Problems?
*
This field is required.
Do you have Asthma Or Other? Do You Smoke?
YES
NO
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25
Please Provide More Information On Your Breathing Problems.
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26
Do You Have Any Eye Problems Or Wear Glasses?
*
This field is required.
Wear Glasses? Other Eye Problems.
YES
NO
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27
When Was Your Last Vision Test?
Please Fill In In The Format: June 2022. If you don't remember, you may leave this blank.
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28
Do You Have Any Hearing Problems?
*
This field is required.
Any Problems Such As Requiring Hearing Aids, Wax Build Up, Deafness, Dizziness (Vertigo) etc.
YES
NO
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29
Please Provide Details On Your Hearing Problems.
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30
Do You Have Any Neurological Problems?
*
This field is required.
Examples Include: Headaches, Seizures, Other etc.
YES
NO
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31
Please Provide More Details On Your Neurological Problems.
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32
Do You Have Any Emotional Disorder(s)?
*
This field is required.
Examples Include: Anxiety, Stress, Sleeping Problems, Depression, etc.
YES
NO
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33
Please Provide More Information On Your Emotional Disorder(s).
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34
Do You Have Any Muscle Or Joint Pains?
*
This field is required.
Any Pain Such As Neck, Back, Knee, Foot, Shoulder, Elbow Pain, Or Any Other Muscle And Joint Pain.
YES
NO
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35
Where Do You Feel The Pain?
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36
Do You Have Diabetes?
*
This field is required.
YES
NO
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37
Have You Had A Bone Density Exam?
If you are over 55 years old, then answer the question please.
No
Yes
I Don't Know What This Is
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38
When Was Your Last Bone Density Exam Done?
Less Than 1 Year.
1-2 Years.
More Than 3 Years.
I Don't Remember.
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39
Would You Like To Discuss Any Lifestyle Or Habitual Concerns With A Doctor On A Future Follow-Up Call?
*
This field is required.
Please select a topic that applies to you
Diet Issues.
Smoking Cessation.
Obesity.
Alcohol/Substance Use.
Stress/Anxiety/Depression Issues.
Sleeping Disorders.
Immunizations/Vaccinations.
Annual Health Exam.
Allergies.
None Of The Above.
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