Care Questionnaire

1

What brings you to PAX Health today?* This field is required.(Choose any that apply)

I’ve been feeling sad, anxious, or stressed

I’m having trouble sleeping or eating

I have trouble concentrating or managing my emotions

I feel like I’m not myself lately

I’ve been feeling hopeless or overwhelmed

I need help managing my medication

I’ve been dealing with trauma or a significant life event

Other

2

Are you currently seeing a mental health provider?* This field is required.

YESNO

3

Have you received treatment in a hospital or outpatient program for mental health in the past?* This field is required.

YESNO

4

Have you ever been diagnosed with a mental health condition?* This field is required.

YESNO

5

Are you currently on any medications?* This field is required.

YESNO

6

What medications are you currently taking?* This field is required.

7

Do you have health insurance?* This field is required.

YESNO

9

Date of Birth* This field is required.

Date

10

Contact Information* This field is required.* Submitting this form is your consent to be reached via email and SMS text. You can opt-out by replying STOP to the first text. Carrier message and/or data rates may apply.

Full Name

Email

Phone

Zip Code