Dr. Navara | Behavioral Health Integration Initial

Patient Information
What is your name? *

First NameLast Name
What is your birthday?*
What is your birthday?*

MonthDayYear

TOBACCO USE (Do you currently smoke?)*

YesNo
How many cigarettes per day do you use?
Are you ready to quit?

YesNo
- Resources for quitting: 1-800-QUITNOW
- Discuss with your Doctor today about treatments to help with tobacco cessation
Your health is important. Let us know if you would like assistance in the future, as quitting is best for your long term health.
Quit
no quit

Do you have any pain in your joints, muscles, back or neck? Hands or feet? Tingling anywhere? Headaches? Weakness or Fatigue?*

YesNo
Would you like to talk to a doctor in the clinic about this?*

YesNo
Thank you. We will schedule you with our providers.
Ok, let us know if we can be of service in the future.

Would you like to talk to a Lifestyle Medicine specialist?

YesNo
Thank you. We will schedule you with our providers.
Ok, let us know if we can be of service in the future.

Do you know your blood pressure?

YesNo
Systolic (high number):
Diastolic (low number):
blood pressure
Should be Empty: