• Image field 281

  • New Patient Intake Form

    FOR YOUR PRIVACY – THIS FORM IS SECURE AND ENCRYPTED.

  • Patient information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Vitals

  • Height*
  • Weight*

  • Emergency Contact

  • Format: (000) 000-0000.

  • Preferred Pharmacy Information

  • Format: (000) 000-0000.

  • Lifestyle Information

  • Sexual and Reproductive Health
  • Are you sexually active?*
  • Do you use protection during sexual activity?*
  • Are you currently pregnant?*
  • Are you trying to become pregnant?*

  • Physical Activity
  • How often do you engage in physical activity or exercise?*
  • What type(s) of physical activity do you regularly engage in?*

  • Diet
  • How would you describe your current diet?*

  • Sleep Quality
  • How would you describe your sleep?*

  • Tobacco and Nicotine Use
  • Do you smoke?*
  • Please select the type and frequency of your current tobacco or nicotine use:*
  • Please specify the type and frequency of tobacco or nicotine products you previously used:*

  • Alcohol Use
  • Do you consume alcohol?*
  • Please specify your alcohol consumption:*
  • Please specify your past alcohol consumption:*
  • Please specify your alcohol consumption:*
  • Please specify your past alcohol consumption:*

  • Social Drugs
  • Do you consume any of the following recreational drugs?*
  • Describe your previous consumption of recreational drugs:*
  • Please specify the type(s) consumed: | Check all that apply*

  • Energy Drinks
  • Do you currently consume energy drinks?*
  • Describe your previous consumption of energy drinks:*

  • Medical History

  • Personal Medical History
  • Have you ever been diagnosed with any of the following medical conditions (currently resolved)? | Check all that apply*
  • If you have been diagnosed with cancer, please specify the type:*
  • If you have been diagnosed with cancer, please specify the type:*
  • If you have been diagnosed with cancer, please specify the type:*

  • Chronic Conditions
  • Do you currently have any of the following chronic conditions? | Check all that apply*
  • If you have been diagnosed with cancer, please specify the type:*
  • If you have been diagnosed with cancer, please specify the type:*
  • If you have been diagnosed with cancer, please specify the type:*

  • Preventive Health & Screening History

  • When was your last 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?*
  • Have you ever had any other screenings performed? (Not listed above)*
  • When was your last you had the other screenings performed?*
  • Rows
  • Rows
  • Rows

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

  • Past Medical Procedures
  • Have you ever undergone any of the following surgical procedures? | Select all that apply*
  • Have you ever undergone any of the following surgical procedures? | Select all that apply*
  • Have you ever undergone any of the following surgical procedures? | Select all that apply*

  • Allergies

  • Do you have any known allergies?*
  • Medication allergies | Do you have any of the following medication allergies*
  • Environmental allergies | Do you have any of the following environmental allergies*
  • Food allergies | Do you have any of the following food allergies*

  • List of Medications

  • Are you currently taking any medications? (Prescription/Over-the-counter)*
  • Are you currently taking any of the following medications?*

  • Family Medical History
  • Does your family have a history of any of the following conditions? | Check all that apply*
  • If your family has a history of cancer, please specify the type:*

  • Mental Health History

  • Have you ever been diagnosed with or experienced any of the following mental health conditions? | Select all that apply*

  • Current Mental Health Treatments
  • Are you currently undergoing treatment for any mental health conditions?*
  • Please indicate the type(s) of treatment(s):*

  • Stress Level (Scale 1-10)

    1 = Minimal stress, 5 = Moderate stress, 10 = Extreme stress.
  •
  • Primary Sources of Stress | Select all that apply*

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

  • Symptom checklist

  • General Symptoms | Select all that apply*
  • Cardiovascular Symptoms | Select all that apply*
  • Respiratory Symptoms | Select all that apply*
  • Gastrointestinal Symptoms | Select all that apply*
  • Musculoskeletal Symptoms | Select all that apply*
  • Endocrine Symptoms | Select all that apply*
  • Hematologic/Lymphatic Symptoms | Select all that apply*
  • Genitourinary Symptoms | Select all that apply*
  • Skin Symptoms | Select all that apply*
  • Neurological Symptoms | Select all that apply*
  • Psychological Symptoms | Select all that apply*

  • Goals and Expectations

  • What are your primary health goals that you hope to achieve by participating in the Discovery+ Program? | Check all that apply*

  • Consent

    I agree to participate in the Discovery+ Program and consent to the collection and use of my health information for program purposes.
  •  - -
  • Should be Empty: