New Patient Pre-Eval Form
Demographics
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
Address
Street Address
City
State
Zip Code
Height
Input Height
Weight
Input Weight
Martial Status
Single
Married
Divorced
Widowed
Separated
Other
Fudning Information
Type of Funding
Medicaid
Commercial
Uninsured
Other
Primary Insurance:
Member ID:
Emergency Contact
Emergneyc Contact Name
First Name
Last Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
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Substance Abuse History
Substance Abuse History
Age of Onset
Method of Use
How often
Date of last use
Avg. 24 hour use amount
Alcohol
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Cocaine
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Marijuana
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Heroin
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Other Opiates
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Hallucinogens
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Methamphetamines / Amphetamines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Stimulants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Benzodiazepines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Inhalants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
K2 / Synthetic Cannabis
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Previous Drug and Alcohol and/or Mental Health Treatment
Have you been involved in previous treatment for D&A or Mental Health services?
Yes
No
Previous D&A and/or MH services.
Dates
Location/Type of Service
D&A Outpatient
D&A Inpatient
MH Outpatient
Tobacco / Smoking
Do you smoke or use tobacco?
Yes
No
For how many years have you used tobacco products?
Type of Tobacco Use
Light Cigarette Smoker (1-9 per day)
Moderate Cigarette Smoker (10-19 per day)
Heavy Cigarette Smoker (20-39 per day)
Chewing Tobacco / Smokeless Tobacco
Nicotine Pouches
Vape/E-Cigarette
Other
Smoking Status
Please Select
Current every day smoker
Current some day smoker
Former Smoker
Never Smoked
Declined to Answer
On a Scale of 1 to 10, How Ready Are You to Quit Tobacco (Circle Below):
Not Ready At All
1
2
3
4
5
6
7
8
9
Very Ready
10
1 is Not Ready At All, 10 is Very Ready
Specify amount and frequency of tobacco/nicotine use:
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Health History
Family Health History
Family Member(s)
Comments
Cancer
Diabetes
Heart Disease
Hypertension
Stroke
Seizure
High Cholesterol
Addition
Psychiatric
Health Problems
Now
Past
Never
Any thoughts?
Anemia
Arthritis
Bleeding Disorder
Blood Pressure
Bone/Joint Problem
Cancer
Diabetes
Epilepsy/Seizures
Eye Disease
Glaucoma
Fibromyalgia
Muscle
Headaches
Head Injury
Brain Tumor
Hearing Problems
Heart Disease
Hepatitis
Kidney Disease
Lung Disease
Menstrual Pain
Oral/Dental Health
Stomach Issues
Stroke
Thyroid
Tuberculosis
AIDS/HIV
STI/STD
Learning Problems
Speech Problems
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Schizophrenia
Sexual Problems
Sleep Disorder
Suicide Attempts
Suicide Thoughts
Medications
Dose/Strength
Frequency
Comments
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Additional Medications
Any known allergies?
Yes
No
Please specify allergies:
Past Surgical Procedures/Serious Injuries
Operation / Hospitalization
Year
Comments
1
2
3
4
Additional
Primary Care Physician
PCP Name
First Name
Last Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Pharmacy
Please enter your prefered pharmacy information below
Pharmacy Name
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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PHQ-9, Trauma History Questionnaire
PHQ-9: Over the past 2 weeks, how often have you been bothered by any of the following problems?
0. Not at all
1. Several Days
2. More than half the days
3. Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat Difficult
Very Difficult
Extremely Difficult
Trauma History Questionnaire
The Following is a series of questions about serious or traumatic life events. Knowing about the occurrence of such events, and reactions to them will help us to develop programs for prevention, education, and other services. For each event, indicate whether it happened &, if it did, the number of times & your approximate age when it happened.
General Trauma History
Yes
No
Number of times
Approximate Age
Comments
Has anyone ever tried to take something directly from you by using force or the threat of force, such as a stick-up or mugging?
Has anyone ever attempted to or succeeded in breaking into your home.
Have you ever been in any situation in which you were serious injured? (is yes, specify)
Have you ever been in any other situation in which you feared you might be killed or seriously injured? (If yes, specify)
Have you ever seen someone seriously injured or killed? (If yes, specify)
Have you ever had a serious or life-threatening illness? (If yes, specify)
Have you ever received news of a serious injury, life-threatening illness, or unexpected death of someone close to you? (If yes, specify)
Has anyone ever pressured or forced you into unwanted physical or sexual contact?
Has anyone, including family or friends, ever attacked you with a gun, knife, or other weapon?
Have you ever experienced, witnessed or been exposed to domestic violence?
Have you experienced any other extraordinarily stressful situation or traumatic event that is not covered above? (If yes, specify)
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TB/HVC/HIV Rick Assessment
HCV Screening Questions
Were you born between the years of 1945 & 1965
Yes
No
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Have you received a clotting factor produced before 1987?
Yes
No
Have you been on hemodialysis?
Yes
No
Human Immunodeficiency Virus Screening Questions
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Do you engage in unprotected sexual activities?
Yes
No
Do you engage in sharing needles?
Yes
No
Tuberculosis Screening Tool
Have you traveled extensively (more than 4 weeks) outside the U.S in the last five years to high TB-incidence areas (Asia, Africa, South America, Central America)?
Yes
No
Are you an immigrant from a high TB-risk foreign country (includes countries in Asia, Africa, South America, and Central America)?
Yes
No
Have you resided in any of these facilities in the past year: jails, prisons, shelters, nursing homes and other long-term care facilities such as rehabilitation centers? (If an individual was a resident of any of these facilities and tested with the past three months, they do not need to be reassessed).
Yes
No
Have you had any close contact with someone diagnosed with TB?
Yes
No
Have you been homeless within the past year?
Yes
No
Have you ever injected drugs?
Yes
No
Do you or anyone in your household currently have the following symptoms, such as a sustained cough for two or more weeks, coughing up blood, fever/chills, loss of appetite, unexplained weight loss, fatigue, night sweats?
Yes
No
Do you currently have or anticipate having any condition that would decrease your immune system? (Examples: HIV infection, organ transplant recipient, treatment with TNF-alpha antagonist (e.g. infliximab, etanercept, others), steroids (equivalent dose of Prednisone 15mg/day for one month or longer) or any other immunosuppressive medications)
Yes
No
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Appointment Request
Date of REqeuested Appointment
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is there anything else you'd like us to know?
By subitting this form via the web portal, you acknowledge and accept that risk of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Jade Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.
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Yes
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