Wellspring New Patient Intake Form

New Patient Intake Form

Please fill out the following information to help us understand your medical history and needs
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Age*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you consent to email, phone call and text for appointment confirmations, reminders and communication about your Health? These are all Wellspring's everyday practices. *

YesNo
Please provide YOUR MOST RELIABLE PHONE NUMBER to receive appointment confirmations, reminders and communication from us about your Health*
Please enter a valid phone number.Format: (000) 000-0000.
Please provide YOUR MOST RELIABLE EMAIL to receive appointment reminders and communication from us about your Health*
example@example.com
Current Relationship status*

MarriedDivorcedPartnershipSingle
Do you have any Children? (Yes or No) If Yes, please indicate how many:*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician Name

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to contact the provider for collaboration of care?

YesNo
Please list your Health Concerns or the reason(s) you'd like to meet us in order of importance:*

Please tell us a little about your Medical History
Do you have any current Diagnoses or Medical Conditions? Please list them and length of time:
Do you have any pertinent Family Medical History to tell us? Please list Family member and their Medical Condition:
Have you had any injuries or surgical procedures? Please list them and the year:
Current Medication Names, Doses, Reason and length you have been taking it:
Current Supplement or Herb Names, Doses, Reason and length you have been taking it:
Do you have any Allergies in the following categories?*
Drug:


Environmental:


Food:
Do you have any of the following?*
Have you had any of the following removed?*
Have you had Botox in the last 6 months? *

YesNo
Women's Health
Have you had a full or partial hysterectomy?

FullPartialNone
Age of first Menstrual cycle:
Do you currently have a Menstrual cycle?
Length of Menses:
Cycle length between Menstruation:
Do you have any of the following Menstrual symptoms?
Do you experience perinatal or postpartum depression? If Yes, please explain:
Have you experienced any of the following? If Yes, how many?
Men's Health
Do you feel any decrease in your ability/frequency to perform sexually? (Yes or No) If Yes, please explain:
Do you feel any decrease in your beard growth? (Yes or No) If Yes, please explain:
Do you feel any decrease in the number of morning erections? (Yes or No) If Yes, please explain:

Please tell us a little about your Lifestyle and daily Life
Do you follow a specific Diet?*
Daily intake*
Water:


Caffeine:


Soda/Pop:
Do you smoke cigarettes? ->*

YesNoQuit
If your answer is Yes or Quit, please answer the following:
No. of packs/day:


How many years:


Year quit:
Do you drink alcohol? (Yes or No) If Yes, how many drinks per week?*
Do you use recreational drugs? (Yes or No) If Yes, please provide more information:*
Do you have a current or past drug or alcohol problem? (Yes or No) If Yes , please provide more information:*
Do you have a history of mental, emotional or physical trauma? (Yes or No) If Yes, please provide more information:*
Do you sleep well? Please explain and include how many hours per night:*
Do you exercise? (Yes or No) If Yes, how many hours per week and type:*
Do you ever feel fatigued? (Yes or No) If Yes, please explain:*
Do you ever experience physical exhaustion or lack of vitality? (Yes or No) If Yes, please explain:*
Do you notice a decrease in muscular strength? (Yes or No) If Yes, please explain:*
Do you feel any decrease in sexual desire/libido or lacking pleasure in sexual intercourse? (Yes or No) If Yes, please explain:*
What is your stress level on a scale of 1-10 (1 being the lowest amount of stress, 10 being the highest)*
What is your energy level on a scale of 1-10 (1 being the lowest amount of stress, 10 being the highest)*
Is there anything else that you would like the Doctor to know about you?

New Patient Intake Form