Discovery+ Program Patient Intake

New Patient Intake Form

FOR YOUR PRIVACY – THIS FORM IS SECURE AND ENCRYPTED.
Patient information
Name*

First NameMiddle NameLast Name
Gender*
Date of Birth*

MonthDayYear
Organization Name*
Health Card Number*
E-mail*
example@example.com
Main Phone Number:*
Preferred Call Type For Discovery+ Appointment*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Medical Doctor
Family Medical Doctor | Fax Number
Please enter a valid phone number.
Vitals
Height*

Feet/InchesCentimeters
Height*
Weight*

Poundskilograms
Weight*
Emergency Contact
Emergency Contact*

First NameLast Name
Relationship to patient*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Pharmacy Information
Name of pharmacy*
Phone number of pharmacy*
Fax number of pharmacy*
Please enter a valid phone number.
Address of pharmacy

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lifestyle Information
Sexual and Reproductive Health
Are you sexually active?*

YesNoPrefer not to answer
Do you use protection during sexual activity?*

YesNoSometimesPrefer not to answer
Are you currently pregnant?*

YesNoPrefer not to answer
Are you trying to become pregnant?*

YesNoPrefer not to answer
Physical Activity
How often do you engage in physical activity or exercise?*

Every day (very active, at least 30 minutes)3-5 times per week (moderate to vigorous intensity)1-2 times per week (light activity)A few times a month (occasional activity)Rarely (less than once a month)Never (no physical activity)
What type(s) of physical activity do you regularly engage in?*

WalkingRunning/JoggingHikingSwimmingBikingStrength training (weights, resistance)Yoga/PilatesGroup fitness classesSports (basketball, soccer, etc.)Other
Diet
How would you describe your current diet?*

Balanced (a mix of fruits, vegetables, protein, grains, and healthy fats)VegetarianVeganLow-carb/KetoHigh-proteinGluten-freeDairy-freeHighly Processed Foods (Junk food)Other
Sleep Quality
How would you describe your sleep?*

Excellent (7-9 hours, uninterrupted)Good (6-8 hours, occasional interruptions)Fair (5-6 hours, restless sleep)Poor (less than 5 hours or very restless)Insomnia (difficulty falling or staying asleep)Sleep apnea (diagnosed)Frequently wake up tiredSleep more than 9 hours but still feel tired
Tobacco and Nicotine Use
Do you smoke?*

Current smokerFormer smoker (quit within the last year)Former smoker (quit more than a year ago)Never smoked
Please select the type and frequency of your current tobacco or nicotine use:*

Current cigarette smoker (less than 10 cigarettes/day)Current cigarette smoker (10-20 cigarettes/day)Heavy cigarette smoker (more than 20 cigarettes/day)Occasional cigarette smoker (smokes occasionally, not everyday)Chewing tobacco user (daily use)Chewing tobacco user (occasional use)Vaping (non-nicotine, daily use)Vaping (non-nicotine, occasional use)Vaping (nicotine, daily use)Vaping (nicotine, occasional use)Social smoker (only smokes in social settings)
Please specify the type and frequency of tobacco or nicotine products you previously used:*

Former cigarette smoker (less than 10 cigarettes/day)Former cigarette smoker (10-20 cigarettes/day)Heavy former cigarette smoker (more than 20 cigarettes/day)Former occasional cigarette smoker (smoked occasionally, not everyday)Former chewing tobacco user (daily use)Former chewing tobacco user (occasional use)Former vaping (non-nicotine, daily use)Former vaping (non-nicotine, occasional use)Former vaping (nicotine, daily use)Former vaping (nicotine, occasional use)Former social smoker (only smoked in social settings)
Alcohol Use
Do you consume alcohol?*

Current consumerFormer consumer (quit within the last year)Former consumer (quit more than a year ago)Never consumed alcohol
Please specify your alcohol consumption:*

Less than 1 drink per week1-3 drinks per week4-6 drinks per week7-10 drinks per weekMore than 10 drinks per week (heavy use)Occasional drinking (not every week)Only in social settings
Please specify your past alcohol consumption:*

Less than 1 drink per week1-3 drinks per week4-6 drinks per week7-10 drinks per weekMore than 10 drinks per week (heavy use)Occasional drinking (not every week)Only in social settings
Please specify your alcohol consumption:*

Less than 1 drink per week1-3 drinks per week4-6 drinks per week7-14 drinks per weekMore than 14 drinks per week (heavy use)Occasional drinking (not every week)Only in social settings
Please specify your past alcohol consumption:*

Less than 1 drink per week1-3 drinks per week4-6 drinks per week7-14 drinks per weekMore than 14 drinks per week (heavy use)Occasional drinking (not every week)Only in social settings
Social Drugs
Do you consume any of the following recreational drugs?*

Never usedOccasional user (less than once a month)Regular user (1-3 times per month)Frequent user (1-2 times per week)Heavy user (more than 2 times per week)Former user (quit more than a year ago)Former user (quit within the last year)
Describe your previous consumption of recreational drugs:*

Occasional user (less than once a month)Regular user (1-3 times per month)Frequent user (1-2 times per week)Heavy user (more than 2 times per week)
Please specify the type(s) consumed: | Check all that apply*

Cannabis/MarijuanaCocaineEcstasy (MDMA)LSD/AcidPrescription painkillers (opioids)Amphetamines (Adderall, etc.)Methamphetamines (Crystal Meth)Other
Energy Drinks
Do you currently consume energy drinks?*

Never consumedOccasionally (less than once a week)Moderate (1-3 times per week)Frequent (4-6 times per week)Daily (more than 6 times per week)Former consumer (quit more than a year ago)Former consumer (quit within the last year)
Describe your previous consumption of energy drinks:*

Occasionally (less than once a week)Moderate (1-3 times per week)Frequent (4-6 times per week)Daily (more than 6 times per week)
Medical History
Personal Medical History
Have you ever been diagnosed with any of the following medical conditions (currently resolved)? | Check all that apply*

Heart diseaseHigh blood pressure (hypertension)High cholesterolStrokeBlood clotting disordersAsthma or respiratory disordersChronic Obstructive Pulmonary Disease (COPD)Diabetes (Type 1 or Type 2)Thyroid disorder (hypothyroid, hyperthyroid)Arthritis (osteoarthritis, rheumatoid)OsteoporosisChronic painAutoimmune disorders (e.g., lupus, MS)Cancer (specify type)Liver disease (e.g., Hepatitis, cirrhosis)Kidney diseaseNeurological disorders (e.g., epilepsy, migraines)Epilepsy/SeizuresGastrointestinal conditions (GERD, IBS, Crohn’s, etc.)NoneOther
If you have been diagnosed with cancer, please specify the type:*

Breast cancerCervical cancerOvarian cancerEndometrial (Uterine) cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
If you have been diagnosed with cancer, please specify the type:*

Prostate cancerBreast cancerCervical cancerOvarian cancerEndometrial (Uterine) cancerTesticular cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
If you have been diagnosed with cancer, please specify the type:*

Prostate cancerTesticular cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
Chronic Conditions
Do you currently have any of the following chronic conditions? | Check all that apply*

Heart diseaseHigh blood pressure (hypertension)High cholesterolStrokeBlood clotting disordersAsthma or respiratory disordersChronic Obstructive Pulmonary Disease (COPD)Diabetes (Type 1 or Type 2)Thyroid disorder (hypothyroid, hyperthyroid)Arthritis (osteoarthritis, rheumatoid)OsteoporosisChronic painAutoimmune disorders (e.g., lupus, MS)Cancer (currently receiving treatment or in remission, specify type)Liver disease (e.g., Hepatitis, cirrhosis)Kidney diseaseNeurological disorders (e.g., epilepsy, migraines)Epilepsy/SeizuresGastrointestinal conditions (GERD, IBS, Crohn’s, etc.)NoneOther
If you have been diagnosed with cancer, please specify the type:*

Prostate cancerTesticular cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
If you have been diagnosed with cancer, please specify the type:*

Prostate cancerBreast cancerCervical cancerOvarian cancerEndometrial (Uterine) cancerTesticular cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
If you have been diagnosed with cancer, please specify the type:*

Breast cancerCervical cancerOvarian cancerEndometrial (Uterine) cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
Preventive Health & Screening History
When was your last full physical exam?*

Within the past year1-2 years ago3-5 years agoMore than 5 years agoNever had a full physical exam
Screenings can include:

Blood Pressure, Cholesterol, Blood Sugar (Diabetes), Mammogram (Breast Cancer Screening), Pap Smear (Cervical Cancer Screening), Colonoscopy (Colorectal Cancer Screening), Bone Density Test (Osteoporosis Screening), Prostate Exam (Prostate Cancer Screening), Skin Cancer Screening, Eye Exam, Hearing Test, CAT Scan (Computed Axial Tomography)
Have you ever had any of the screenings listed above performed?*

YesNo
Have you ever had any other screenings performed? (Not listed above)*

YesNo
Please specify other screenings performed: (Not listed above)*
When was your last you had the other screenings performed?*

Within the past year1-2 years ago3-5 years agoMore than 5 years ago

Vaccinations
Have you received any of the following vaccinations? | Check all that apply*

Influenza (Flu Shot)COVID-19Diphtheria, Tetanus, Pertussis (DTaP)Polio (IPV)Haemophilus influenzae type b (Hib)Hepatitis BMeasles, Mumps, Rubella (MMR)Varicella (chickenpox)Human Papillomavirus (HPV)Meningococcal (Men-C-C or Men-C-ACYW)Pneumococcal (Pneumonia) (Pneu-C-13, Pneu-P-23)RotavirusNoneOther
Past Medical Procedures
Have you ever undergone any of the following surgical procedures? | Select all that apply*

AppendectomyGallbladder removalHeart surgery (e.g., bypass, stent placement)Joint replacement (e.g., hip, knee)TonsillectomyC-SectionHysterectomyMastectomyLumpectomyOophorectomySalpingectomyD&C (Dilation and Curettage)Laparoscopy for EndometriosisVaginal HysterectomyPelvic Floor SurgeryNoneOther
Have you ever undergone any of the following surgical procedures? | Select all that apply*

AppendectomyGallbladder removalHeart surgery (e.g., bypass, stent placement)Joint replacement (e.g., hip, knee)TonsillectomyC-SectionHysterectomyMastectomyLumpectomyOophorectomySalpingectomyD&C (Dilation and Curettage)Laparoscopy for EndometriosisVaginal HysterectomyPelvic Floor SurgeryProstate surgeryHernia repairVasectomyCircumcisionCarpal tunnel releaseColon surgeryNoneOther
Have you ever undergone any of the following surgical procedures? | Select all that apply*

AppendectomyGallbladder removalHeart surgery (e.g., bypass, stent placement)Joint replacement (e.g., hip, knee)TonsillectomyProstate surgeryHernia repairVasectomyCircumcisionCarpal tunnel releaseColon surgeryNoneOther
Allergies
Do you have any known allergies?*

YesNo
Medication allergies | Do you have any of the following medication allergies*

PenicillinSulfa drugsNSAIDs (e.g., ibuprofen, aspirin)Narcotics (e.g., codeine, morphine)AntibioticsNoneOther
Environmental allergies | Do you have any of the following environmental allergies*

PollenDust mitesMoldPet danderLatexNoneOther
Food allergies | Do you have any of the following food allergies*

Nuts (tree nuts or peanuts)ShellfishDairyEggsGlutenSoyNoneOther
List of Medications
Are you currently taking any medications? (Prescription/Over-the-counter)*

YesNo
Are you currently taking any of the following medications?*

Blood pressure medicationsDiabetes medications (insulin or oral)Blood thinners (e.g., warfarin, aspirin)Cholesterol-lowering medications (statins)Antidepressants or anti-anxiety medicationsPain relievers (e.g., NSAIDs, opioids)Asthma or COPD medications (inhalers)Thyroid medicationsBirth control or hormone replacement therapyAntihistamines or allergy medicationsVitamins/SupplementsPain Medication (Prescription/Over-the-counter)Other
Family Medical History
Does your family have a history of any of the following conditions? | Check all that apply*

Heart diseaseHigh blood pressure (hypertension)High cholesterolStrokeBlood clotting disordersAsthma or respiratory disordersChronic Obstructive Pulmonary Disease (COPD)Diabetes (Type 1 or Type 2)Thyroid disorder (hypothyroid, hyperthyroid)Arthritis (osteoarthritis, rheumatoid)OsteoporosisChronic painAutoimmune disorders (e.g., lupus, MS)Cancer (specify type)Liver disease (e.g., Hepatitis, cirrhosis)Kidney diseaseNeurological disorders (e.g., epilepsy, migraines)Epilepsy/SeizuresGastrointestinal conditions (GERD, IBS, Crohn’s, etc.)NoneOther
If your family has a history of cancer, please specify the type:*

Prostate cancerBreast cancerCervical cancerOvarian cancerEndometrial (Uterine) cancerTesticular cancerLung cancerColorectal cancerSkin cancer (e.g., melanoma, basal cell carcinoma)Bladder cancerKidney cancerPancreatic cancerLiver cancerEsophageal cancerStomach (Gastric) cancerLeukemiaLymphomaMultiple myelomaBrain and central nervous system cancersThyroid cancerHead and neck cancersBone cancerOther
Mental Health History
Have you ever been diagnosed with or experienced any of the following mental health conditions? | Select all that apply*

Anxiety disorder (generalized anxiety, social anxiety, panic disorder)Depression (major depressive disorder, persistent depressive disorder)Bipolar disorder (Type I, Type II, cyclothymic disorder)ADHD (Attention Deficit Hyperactivity Disorder)PTSD (Post-Traumatic Stress Disorder)OCD (Obsessive-Compulsive Disorder)Eating disorder (anorexia, bulimia, binge eating disorder)Substance abuse disorderBorderline Personality Disorder (BPD)Schizophrenia or schizoaffective disorderAutism Spectrum Disorder (ASD)Sleep disorders (insomnia, sleep apnea)Other mood disorders (e.g., dysthymia)NoneOther
Current Mental Health Treatments
Are you currently undergoing treatment for any mental health conditions?*

YesNoPrefer not to answer
Please indicate the type(s) of treatment(s):*

Medication (e.g., antidepressants, anti-anxiety medication)Therapy (e.g., cognitive-behavioral therapy, counseling)Other
Stress Level (Scale 1-10)

1 = Minimal stress, 5 = Moderate stress, 10 = Extreme stress.

	When was your last screening?
Blood Pressure
Cholesterol
Blood Sugar (Diabetes)
Mammogram (Breast Cancer Screening)
Pap Smear (Cervical Cancer Screening)
Colonoscopy (Colorectal Cancer Screening)
Bone Density Test (Osteoporosis Screening)
Skin Cancer Screening
Eye Exam
Hearing Test
CAT Scan (Computed Axial Tomography)

	When was your last screening?
Blood Pressure
Cholesterol
Blood Sugar (Diabetes)
Mammogram (Breast Cancer Screening)
Pap Smear (Cervical Cancer Screening)
Prostate Exam
Colonoscopy (Colorectal Cancer Screening)
Bone Density Test (Osteoporosis Screening)
Skin Cancer Screening
Eye Exam
Hearing Test
CAT Scan (Computed Axial Tomography)

	When was your last screening?T
Blood Pressure
Cholesterol
Blood Sugar (Diabetes)
Colonoscopy (Colorectal Cancer Screening)
Bone Density Test (Osteoporosis Screening)
Prostate Exam
Skin Cancer Screening
Eye Exam
Hearing Test
CAT Scan (Computed Axial Tomography)

	1	2	3	4	5	6	7	8	9	10

1 is Minimal stress, 10 is Extreme stress

Primary Sources of Stress | Select all that apply*

WorkFamily/relationshipsFinancial concernsHealth issuesNone
Family Mental Health History
Does your family have a history of any of the following mental health conditions? | Select all that apply*

Anxiety disorder (generalized anxiety, social anxiety, panic disorder)Depression (major depressive disorder, persistent depressive disorder)Bipolar disorder (Type I, Type II, cyclothymic disorder)ADHD (Attention Deficit Hyperactivity Disorder)PTSD (Post-Traumatic Stress Disorder)OCD (Obsessive-Compulsive Disorder)Eating disorder (anorexia, bulimia, binge eating disorder)Substance abuse disorderBorderline Personality Disorder (BPD)Schizophrenia or schizoaffective disorderAutism Spectrum Disorder (ASD)Sleep disorders (insomnia, sleep apnea)Other mood disorders (e.g., dysthymia)NoneOther
Symptom checklist
General Symptoms | Select all that apply*

Unexplained weight lossFatigueFeverNight sweatsWeaknessLoss of appetiteRecent illnessChillsNoneOther
Cardiovascular Symptoms | Select all that apply*

Chest painPalpitations (irregular heartbeats)Shortness of breath on exertionSwelling in legs or feetHigh blood pressureNoneOther
Respiratory Symptoms | Select all that apply*

Chronic coughWheezingShortness of breathCoughing up bloodNoneOther
Gastrointestinal Symptoms | Select all that apply*

NauseaVomitingDiarrheaConstipationBlood in stoolNoneOther
Musculoskeletal Symptoms | Select all that apply*

Joint painMuscle weaknessBack painStiffnessSwelling of jointsNoneOther
Endocrine Symptoms | Select all that apply*

Increased thirstIncreased urinationUnexplained weight changesHair lossHeat or cold intoleranceNoneOther
Hematologic/Lymphatic Symptoms | Select all that apply*

Easy bruisingFrequent nosebleedsSwollen lymph nodesAnemiaBleeding gumsNoneOther
Genitourinary Symptoms | Select all that apply*

Painful urinationFrequent urinationBlood in urineIncontinenceErectile dysfunctionNoneOther
Skin Symptoms | Select all that apply*

RashItchingChanges in molesDrynessHair lossNoneOther
Neurological Symptoms | Select all that apply*

HeadachesDizzinessNumbness/tinglingMemory lossSeizuresNoneOther
Psychological Symptoms | Select all that apply*

AnxietyDepressionInsomniaDifficulty concentratingMood swingsSuicidal thoughtsNoneOther
Goals and Expectations
What are your primary health goals that you hope to achieve by participating in the Discovery+ Program? | Check all that apply*

Smoking cessationStress managementBetter nutritionImproving physical fitnessEnhancing mental healthImproving cardiovascular healthIncreasing energy levelsWeight management, maintain weightWeight management, gain weightWeight management, lose weightManaging chronic diseasePreventative healthImproving sleep qualityEnhancing overall well-beingBuilding healthy habitsGetting more regular check-upsOther
Consent

I agree to participate in the Discovery+ Program and consent to the collection and use of my health information for program purposes.
Participant's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake Form

Patient information

Vitals

Emergency Contact

Preferred Pharmacy Information

Lifestyle Information

Medical History

Preventive Health & Screening History

Screenings can include:

Allergies

List of Medications

Mental Health History

Stress Level (Scale 1-10)

Symptom checklist

Goals and Expectations

Consent