SpokeMed New Patient Intake Form

Patient Name*

First NameLast Name

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Birth Date*

MonthDayYear

Patient Gender*

Patient E-Mail*

example@example.com

Pharmacy name, address, phone number

Reason for seeing the provider and symptoms:*

Patient Height (feet and inches)*

Patient Weight (lbs)*

Have you ever had (Please check all that apply)

Other Medical Conditions or Problems:

Please list any past surgeries, medical procedures, major injuries, or hospitalizations (include reason for hospitalization) and dates of each.

When was the last time you completed labwork (month and year). Specify any abnormal results.

Please list your current medications, vitamins/supplements, strength and frequency. Remember to include over the counter medications. If too many to list, email me your medication list to Michelle@spokemed.com

Medication Allergies

Occupation

Relationship status

Have you ever been pregnant? How many times?

How many children do you have?

Who lives at home with you?

Do you feel safe at home?

YesNo

If no, Why?

Exercise

Never1-2 days3-4 days5+ days

Eating Habits

I have a loose dietI have a strict dietI don't have a diet plan

Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Alcohol Consumption- Drinks blanks per day blankper week

Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day

What medical conditions are in your family (mother, father, siblings, children) including cancer, diabetes, heart disease, etc. and at what age they developed the disease.

If you don't have an appointment scheduled for your zoom consult, schedule your appointment here.

The information provided in this questionnaire is true and complete to the best of my knowledge. I understand that the accuracy of the information I have provided is important to my physician and my healthcare team in order to develop an individualized care plan for me.

CONSENT TO BASIC TREATMENT AND DIAGNOSTIC PROCEDURES I consent to any medication assessment and management, laboratory or other medical procedures or examinations rendered me under the general and specific instructions of SPOKEmed providers.

PRIVACY POLICY. Recognizing that certain services provided are of confidential nature, SPOKEmed providers has formally adopted a policy to protect your privacy. This policy states that the information you provide to me will be kept confidential and will not be distributed or shared with other persons or organizations without your written approval. However, there are situations where SPOKEmed providers has a responsibility to release information, regardless of whether the patient agrees.

RELEASE OF INFORMATION AND CONFIDENTIALITY OF RECORD I authorize release of information to other health care providers, institutions and referral sources for the purpose of diagnosis, treatment, consultation and professional communication.

PAYMENT Patients are expected to pay any fees due prior to the consultation.

CANCELLATION POLICY Since scheduling of an appointment involves the reservation of time, a minimum of 24 hours cancellation notice is required for rescheduling or canceling an appointment.

MISSED APPOINTMENTS AND CHARGES ASSOCIATED WITH THEM ARE YOUR RESPONSIBILITY. If 24 hours cancellation notice has not been given, there will be a charge of $50 for medical visits.

MEDICATION MANAGEMENT / REFILL REQUESTS / CHANGES IN MEDICATION

When treatment involves medications, you will be provided with enough prescription refills to last until your next scheduled appointment. If you need to cancel that appointment, you will need to reschedule before your medication runs out. Medication changes will not be made over the phone without consent from the prescriber. In case of an emergency, please call 911 or go to the nearest emergency room. Patient expectations for safe and effective medication management require that the patient:

1. Inform SPOKEmed providers when any new medical problems or medication that is prescribed by other health care professionals, and of any over the counter medications or supplements.
2. Inform SPOKEmed providers of any side effects or suspected side effects of medication.
3. Agree not to make changes in medication dosing, including stopping medications without consulting with SPOKEmed providers. NOTE: IT MAY BE DANGEROUS TO ABRUPTLY STOP SOME MEDICATIONS OR CHANGE DOSING WITHOUT CONSULTATION WITH A MEDICAL PROFESSIONAL.
4. Attend all scheduled appointments as agreed upon in order to provide proper continuity of care and to properly assess efficacy of treatment.
5. Complete all requested laboratory testing in a timely manner for the evaluation of safety and efficacy.

Signature

I authorize SPOKEmed to send me emails and text messages for appointment reminders. Message and data rates may apply.

How did you hear about SPOKEmed?

Please verify that you are human*

General Patient Information

Patient Medical History

Social History

Family Medical History