Existing patient form

New Patient Intake form

for any fields that do not apply to you, please leave blank unless otherwise indicated.
What services are you seeking?
Contact Information
Patient name

First NameMiddle NameLast Name
Preferred name:
Preferred pronouns:
Patient Birthday

MonthDayYear
Date
If the person completing this form IS NOT the patient listed above, please provide you name and relation to the patient.
Patient Social Security number:
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email:
How do you prefer we communicate with you?
Who is your insurance carrier? (ex: BCBS, Aetna, Soonercare). If you don’t have insurance, write self-pay.
File Upload

Please upload a picture of the FRONT SIDE of your insurance card.
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File Upload

Please upload a picture of the BACK SIDE of your insurance card.
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What pharmacy would you like us to send medication to? (Please provide name and address).
How were you referred to our clinic? (if you weren't referred, leave blank)
Tell us a bit about why you want to schedule an appointment:
Demographics
Please list your gender-identity (ex: male, female, non-binary, etc.)
Please list your sexual orientation:
Marital status:

SingleMarried/long-term relationshipDivorcedWidowed
Partner's name and age:
Length of relationship?
Please list the people living in your home:
Please list any children with ages and where they reside:
What is your religious affiliation?
Are there any cultural/ethnic/spiritual considerations you would like us to know about?
What do you like to do in your free time/down time?
Do you have any issues making or keeping friends? (if no, write n/a).
Please list any past or ongoing legal issues:
Highest level of education:
Did you deal with any of the following school related issues?

504 Plan/IEPSkipped gradesHeld back a gradeExpulsionOccupational therapySpeech therapyPhysical therapySuspension (in school)Suspension (out of school)BullyingRequire special help
Employment status:
What do you do for work? (if you don't work, write n/a).
Any past military experience? (if no, write n/a).
Medical History
Height:
Recent weight:
Date of last Physical Exam:
Please provide the name and number of your Primary Care Provider (write n/a if you don’t currently have one).

Have you or someone in your immediate family been diagnosed with any of the following:

Rows	Patient	Mom	Dad	Sibling	Child	Other
Anemia
Asthma
Cancer Leukemia
Cerebral Palsy
Diabetes
Down's Syndrome
Encephalitis
Epilepsy/seizures
Hearing Problems
Heart disease
HIV/AIDS
Hypertension
Loss of consciousness/head injury
Meningitis
Musculo-skeletal condition
Stroke
Thyroid Problems
Vision Problems
Dementia/Alzheimer's

Please list ANY OTHER serious and/or chronic illnesses you have (if none, write n/a):
Please list any past surgeries with approximate dates:
Are you sexually active?
If yes, what contraception method do you use?
Have you currently, or have you recently experienced any of the following symptoms:

ChillsChronic painBlurred/double vision/vision changeWeight gainWeight lossFeverChest painChest tightnessLower extremity swellingSexual dysfunctionIncontinenceFaintingFrequent headachesSeizureEye painChronic coughShortness of breathJoint pain/swellingMuscle painHeartburnItchingSinus pressure/congestion/drainageSore throatSkin lesions/rash/hivesFrequent constipationFrequent diarrheaNauseaVomitingCold or heat intoleranceFrequent urination
Any medication, food, or environmental allergies? What type of allergic reaction do you have? (write NKDA if none):
Please list all CURRENT NON-PSYCHIATRIC prescription medications, as well as any supplements, vitamins, or over-the-counter medications you take on a regular basis. Please include the strength and directions (ex: Lisinopril 10 mg every morning, Olly Sleep Gummy every night as needed for sleep.) If you are not on any medications, write n/a.
Behavioral Health History
Please list any CURRENT psychiatric medications, including medication strength and instructions (ex: Prozac 20 mg every morning). If you are not on any medications, write n/a.
Please list any PAST psychiatric medications including medication strength and response (ex: "worked well", "made my anxiety worse", "caused a rash"). If you have not been on any psychiatric medications before, write n/a.
Please list any PAST behavioral health care (inpatient, outpatient, psychological testing) along with approximate dates and provider names.
List any past suicide attempts or history of self-harm with dates.
If you are currently seeing therapy, please provider their name and office name.

Have you or someone in your family been diagnosed with any of the following:

Rows	Patient	Mom	Dad	Sibling	Child	Other
ADD/ADHD
Anxiety
Bipolar Disorder
Depression
DMDD
Eating Disorder
Encopresis/Enuresis
Hallucinations/Delusions/Paranoia
Learning/developmental disorder
OCD
ODD
Panic Attacks
Personality Disorder
PTSD
Schizophrenia
Substance Abuse/Dependency

Do you have any of the following sensory issues?

Overly sensitive to soundsLight sensitivityTexture issuesCoordination issues
Age of mother at time of birth?
Age of father at time of birth?
Did your mother use any of the following during pregnancy?

AlcoholCigarettesMarijuanaCocaine/crackOpiates/Heroinother illicit substances
How often do you exercise?
How would you describe your diet/eating habits?
Examples of typical diet:
Do you or have you smoked cigarettes?
Do you or have you used other forms of nicotine?
Do you drink alcohol?
Do you or have you consumed cannabis (marijuana)?
Do you or have you used methamphetamines?
Do you or have you used cocaine?
Do you or have you used hallucinogens?
Any other current or past substance use/abuse/dependency?
Should be Empty:

New Patient Intake form

Contact Information

Demographics

Medical History

Behavioral Health History