New Patient Screening Questionnaire

Patient Questionnaire

Thank you for taking a few minutes to complete this questionnaire. It will help your doctor focus on the problems that have brought you to our practice and allow more time for you to get your question and concerns fully addressed.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemale
Email Address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Personal Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Person

NamePhone Number
YesNo

Photo of Health Insurance Card (Front)

Cancelof
Photo of Health Insurance Card (Back)

Cancelof
YesNo
When was your last visit with your primary care doctor?
Date or Time Frame
YesNo
Telemedicine VisitIn Person at OfficeIn Person at Home
Health Goals

This section asks what you hope to accomplish in partnering withh us for your health.
What are your five (5) top healthcare goals? How have you tried to achieve them this far? *
Nutrition and dietary changesStress reductionWeight lossImprove sleep qualityOver-all health maintenanceOther
Who is your support system in your health care decision-making> *
Past and Present Medical History

Your previous and current health status.
Alcohol/Drug ProblemAnemiaAnxietyAsthmaDiabetesCancerEmphysema/COPDHearth disease (Atrial Fibrillation, Heart attack, Coronary artery disease, Heart failure)High blood pressureHigh cholesterolKidney diseaseLiver diseaseStrokeSeizure disorderThyroid problemsNoneOther

When was your last time you had the following test/examination?

Please list down all medications*
Note: Kindly include dose and frequency.
Preferred Pharmacy*
Provide pharmacy name and location (address).
Please list down any allergies and reactions*
I agree
Weight
Height
How did you hear about us?
Thank you!

Our doctors will be reviewing your response and will reach out to you shortly.
Should be Empty:

Patient Questionnaire