Dr. Navara | Behavioral Health Integration Follow Up

Patient Information
What's your name?

First NameLast Name
What is your birthday?
What's your birthday?

MonthDayYear
Has your address changed?
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your contact phone number changed?
New Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Has your insurance information changed?
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New Primary Insurance Plan Name:
New Primary Insurance ID Number:
Group Number:
Patient’s Relationship to Policy Holder:
Insurance ID card (Front):
Insurance ID card (Back):
Please upload or take a photo of your Insurance ID card (Front):

Cancelof
Please upload or take a photo of your Insurance ID card (Back):

Cancelof
Do you have a secondary insurance
Secondary Insurance Plan Name:
Secondary Insurance ID Number:
Group Number:
Patient’s Relationship to Policy Holder:
Insurance ID card (Front):
Insurance ID card (Back):
Please upload or take a photo of your Insurance ID card (Front):

Cancelof
Please upload or take a photo of your Insurance ID card (Back):

Cancelof

Rows	Never	Mothly or less	2-4 times a month	2-3 times a week	4 or more times a week
How often do you have a drink containing alcohol?

Rows	0 or 2	3 or 4	5 or 6	7 or 9	10 or more
How many drinks containing alcohol do you have on a typical day when you are drinking?

Rows	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often do you have six or more drinks on one occasion?

TOBACCO USE (Do you currently smoke?)
How many cigarettes per day do you use?
Are you ready to quit?
- 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 know your blood pressure?
Systolic (high number):
Diastolic (low number):
blood pressure

Do you have any pain in your joints, muscles, back or neck? Hands or feet? Tingling anywhere? Headaches? Weakness or Fatigue?
Would you like to talk to a doctor in the clinic about this?
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?
Thank you. We will schedule you with our providers.
Ok, let us know if we can be of service in the future.

Do you have any new medical conditions or allergies since your last visit that you would like us to know about?
New medical conditions or allergies:
Should be Empty:

Patient Information

Behavioral Health Integration

AUDIT

Body Mass Index (BMI) Calculator

LETS SEE YOUR WEIGHT STATUS