Medical Patient Intake Form

Tobacco Use (Select all that apply)*

Never SmokedEx-SmokerEx-user of moist powdered tobaccolight cigarette smoker (1-9 / day)Moderate cigarette smoker (10-19 / day)Heavy cigarette smoker (20-39 / day)Ver heavy cigarette smoker (40+ / day)VapeCigar SmokerPipe SmokerChews tobaccoSnuffOther

1.) How often d you have a drink containing alcohol?*

2.) How many standard drinks containing alcohol do you have per day?*

3.) How often do you have 6 or more drinks on a single occasion?*

NeverMonthly or lessWeeklyDaily

Describe your difficulty paying for the very basics like food, housing, medical care and utilities.*

What is the highest level of education completed?*

1.) How many days in the last week have you engaged in moderate to strenuous exercise such a a brisk walk or working out at the gym*

2.) On those days that you engage in moderate to strenuous exercise how many minutes did you exercise*

Do you feel stress, tense, restless, nervous, anxious or unable to sleep at night because your mind is troubled all the time.*

1.) Are you married, widowed, divorced, separated, never married or living with partner?*

2.) In a typical week, how many times do you talk on the telephone with family, friends, or neighbors*

3.) In a typical week, how often do you get together with friend or relatives?*

4.) In a typical year how many times do you attend church or religious services?*

5.) Do you belong to any clubs or organizations such as with church, group unions, fraternal or athletic groups or school groups?*

YesNo

1.) Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?*

YesNoDecline to answer

2.) Within the last year, have you been afraid of your partner or ex-partner?*

YesNoDecline to answer

3.) Within the last year, have you been raped or forced to have any kind of sexual activity against your will by your partner or ex-partner?*

YesNoDecline to answer

4.) Within the last year, have you been kicked, hit, slapped, or otherwise hurt by your partner or ex-partner?*

YesNoDecline to answer

Gender Idenity*

Sexual Orientation*

Average hour of sleep per night?*

Patient Intake Form

Previous Behavioral Health Medication

Tobacco use

Alcohol use

Financial Resources

Education

Physical Activity

Stress

Social Isolation and Connection

Exposure to Violence

Gender Idenity

Sexual Orientation