Medical Intake Form

intake form

All About You:
This intake and subsequent surveys will guide treatment decision making for medically supervised weight management, major depressive disorder, and/or generalized anxiety disorder. This includes eligibility for the programs as well as guidance for which medications we can prescribe you. Final diagnosis and treatment plan is at discretion of attending physician.

CLICK HERE TO READ CONSENT TO TREATMENT AND PRIVACY POLICY
I have read the privacy policy and consent to treatment and agree to the following:*

I consent to receive medical treatment through an asynchronous telemedicine encounter. I understand in case of emergency or impending self-harm I should seek in-person medical attention by going to an emergency room or calling 911 immediately.
Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Message alerts will be texted here
Upload Photo ID, Front (Driver's License Preferred)*

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender (assigned at birth)
I agree that I am a resident of or present in the state of Texas for the duration of this care encounter*
Gender identity (if different)
Allergies
Do you have any allergies?

YesNo
If yes, please list them and the reaction
e.g. Penicillin - rash
Medical History
Past Medical History Including Psychiatric
e.g. diabetes mellitus 2, seasonal allergies, hypertension, major depressive disorder
Family Medical History
e.g. diabetes - father, high blood pressure - grandmother
Past Surgical History
Medications (name, dose, frequency)
medications currently taken. e.g. lisinopril 10mg pill daily, insulin 10 unit injection 3x a day
Please list any nicotine, alcohol, or substance use (list none if none taken)
e.g. alcohol 1-2 drinks a week, cigarettes 1 pack per day for 10 years, marijuana monthly
Preferred Pharmacy:
pharmacy name, address, phone number (if known)
What can we help you with today? (check to bring up survey below)

Medically Supervised Weight ManagementMajor Depressive Disorder Diagnosis and TreatmentGeneralized Anxiety Disorder Diagnosis and TreatmentEverything Else
Are you above your ideal weight and have a desire to reduce your body weight to promote good health?*

YesNo
Please enter your current weight and height. This program is designed for BMI greater than 25.*
Do you have any of the following? Select any that apply.*

Diabetes Mellitus Type 2High CholesterolHeart DiseaseCurrent Pregnancy or Possible PregnancyAnorexia or BulemiaNone of the Above
Eligibility for semaglutide (GLP-1 type medication, promotes fullness). Do you have or have you ever had any of the following?*

Personal or family history of multiple endocrine neoplasia (MEN-1 or MEN-2)Allergy to semaglutide or any other medication in its classHistory of thyroid cancerHistory of acute pancreatitisLow blood sugar (hypoglycemia)Active gall bladder diseaseKidney diseaseGastroparesis or delayed gastric emptyingNone of the Above
Eligibility for other medications (topiramate, bupropion). Do you have or have you ever had any of the following?*

Excessive alcohol use such as drinking every day or drinking more than 3 to 4 alcoholic drinks in a single setting most days of the weekAllergy to bupropion, topiramate, or branded versions of eitherSeizure disorderKidney stonesStevens-Johnson SyndromeCurrent use of: isocarboxazid, phenelzine, selegiline, or tranylcypromineNone of the Above
Please enter any additional questions or information relevant to your weight management journey you would like to include.
Major depressive disorder is a medical condition characterized by depressed mood, anhedonia (loss of interest or pleasure in things you normally enjoyed), hopelessness, thoughts of self harm, sleep disturbance (too much or too little), loss of interests, unexplained guilt, depressed mood, low energy level, difficulty with concentration, sudden increase or decrease in appetite, sluggishness/feeling weighted down. People will often feel like they are in an inescapable mood or state and they have difficulty mustering the energy to even begin to address the issue.

Depression is frequently the product of both genetic predisposition to abnormal function and presence of neurotransmitters such as serotonin, dopamine, and norepinephrine. These chemicals are targeted by medications that may help improve neurotransmitter levels. This allows you to experience your environment and emotions in way that is free of potentially dysfunctional neural pathways.
Are you diagnosed with any of the below?*

Major Depressive DisorderGeneralized Anxiety DisorderPanic DisorderBipolar DisorderSchizophrenia or Delusional DisorderNone of the Above
Please list any psychiatric medication that you have taken or are taking now such as escitalopram (Lexapro), fluoxetine (Prozac), or sertraline (Zoloft). Please also note if it is effective or not effective.
e.g. escitalopram 20mg daily - effective
In the last 2 weeks have you experienced on most days:*

Sleep disturbance (too much or little), despite adequate sleepLoss of interest in the things you normally enjoyUnexplained guilt or hopelessnessDepressed mood or feeling downLow energy levelDifficulty concentrating or focusingSudden increase or decrease in appetite or food intake (not feeling like eating ever or feeling compelled to eat more than usual)Sluggishness or feeling weighted down as if your limbs are are physically heavy or difficult to moveThoughts of self-harm or suicide (if you have current and active thoughts of suicide or self-harm, please immediately be seen in person by a healthcare professional)None of the Above
If any of the symptoms mentioned are present, are they having a negative impact on your ability to live your daily life?*

YesNoNo symptoms present
Do you currently use any illicit substances such as methamphetamine, marijuana, cocaine, heroin, or do you overuse prescription medications? (All answers are confidential and used exclusively for your healthcare. Doctor-patient confidentiality is fully respected in this clinic.)*

MarijuanaMethamphetamineCocaineHeroinPrescription drugs without a prescriptionNone of the Above
Have you ever had a manic episode? Mania is defined as a hyperactive state of mind characterized by high energy, excitement, and euphoria most days for at least one week. The symptoms may be difficult to control and can lead to impulsive behaviors or risk taking that you would not otherwise undertake.*

YesNoNot Sure
Do you or have you ever seen and heard things that you know were not there (i.e. visual or auditory hallucinations)? If this occurred during an acute illness such as fever or under influence of a substance please mark "No" below*

YesNoNot Sure
Do you have a history of hypothyroidism, thyroid surgery, thyroid cancer, or any thyroid disease?*

YesNoYes, hypothyroid, but it is well controlled
If you have depressed mood, did it begin shortly after a major stressful event such as losing a job, relationship difficulties, or a major medical illness?*

YesNoNot applicable
If yes above, please specify the nature of the stressful event in as much or as little detail as you like to help guide diagnosis. Depression symptoms directly caused by a stressful event are often self-limited to the end of stress surrounding that event. In this situation, medications are not as likely to help.
Please agree to the term below. Depression can lead to intrusive thoughts of self harm and can indicate danger just like chest pain can indicate a dangerous heart condition. It's important to be sure you are safe now and during treatment as some thoughts of self-harm can initially become louder or more apparent during the first couple days or weeks of medication. The theory for why this happens is because medications can improve energy levels earlier than they improve mood.*

I agree to seek help immediately if I am having or begin to have thoughts of self-harm or suicide.
Anxiety refers to a set of symptoms including, but not limited to, excessive worry or anxiety about health, work, interpersonal relationships, or other life events. These worries can seem realistic but tend to be out of proportion with the reality of the stressor. Anxiety can impact someone’s life causing panic attacks or distracting thoughts that are difficult or impossible to get rid of. Intrusive thoughts and habits can make work, school, and personal life hard to manage or enjoy. Anxiety is thought to be a disruption of brain chemicals called neurotransmitters. Too much or too little activity of certain neurotransmitters is an identifiable cause of many psychiatric illnesses and is very strongly linked to genetics and family history. Anxiety does not result from a failing of character, lack of personal quality, or an inability to deal with life.
Do you have excessive worry or anxiety about events or activities that negatively impacting your daily life?*

YesNo
If yes, have these worries/anxieties been present more days than not for the past 6 months or more?*

YesNoNot applicable
Do you find it difficult to control your worry?*

YesNo
Do you have panic attacks (abrupt surge of intense fear or discomfort that occurs from a calm or anxious state, may include palpitations, uncontrolled thoughts, unexplained fear, difficulty regulating breathing)?*

YesNo
Please list any psychiatric diagnoses, if any, you are diagnosed with below, any medications you may have tried, and if a medication helped.
e.g. generalized anxiety disorder, panic disorder, major depressive disorder, or schizophrenia
Do you experience any of the following?*

Restlessness, feeling on edgeEasily fatiguedDifficulty concentratingMind blankingIrritability without explanation or reasonable causeUnexplained muscle tensionDifficulty falling or staying asleepNone of the Above
Have you been diagnosed with any of the following?*

Post-Traumatic Stress Disorder (PTSD)HyperthyroidismHypothyroidismChronic fatigue syndromeObstructive sleep apneaSubstance abuse disorderNone of the Above
Did any of your listed symptoms in the above questionnaire begin as a result of a single identifiable traumatic event or series of traumatic events?*

YesNo
Do you have nightmares or flashbacks to any traumatic events?*

YesNo
Have you ever had a manic episode? Mania is defined as a hyperactive state of mind characterized by high energy, excitement, and euphoria most days for at least one week. The symptoms may be difficult to control and can lead to impulsive behaviors or risk taking that you would not otherwise undertake.*

YesNoNot sure
Are any symptoms you are having listed in this survey been interfering in your ability to function in your daily life?*

YesNoNot sure
Please list any other comments, concerns, symptoms, or details below for the doctor to review.
Concerns that can be handled through online visits include:
Sinus infections, medication management (for certain medications), emergency refills, oral contraceptives, allergy medications, generic viagra, female simple urinary tract infection, work notes, simple rashes, narcan prescriptions, insomnia, gender affirming care (requires video visit), hormone level check and replacement, and general medical questions/review.
Please enter your concern in as much detail as possible:
If it is a general medicine concern that can be handled online, we can help!
How did you hear about us?*

FacebookRedditInstagramThrough a Friend/FamilySearch Engine (Google, Yahoo, etc.)In Person EventOther:
Please select which event(s):

Circle of BarhavenComicpaloozaFolklore FestivalHouston PrideTexas Renaissance FestivalOther
Should be Empty:

intake form

Allergies

Medical History