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
Phone Number*
Please enter a valid phone number.
Email Address*
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.
Primary Care Physician Name

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.
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 Botox in the last 6 months? *

YesNo
Women's Health
Do you currently have a Menstrual cycle?
Age of first 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?

How did you hear about us?*

Friend or FamilyInstagramFacebookWebsiteOther
May we phone, email or send you a text to confirm appointments?*

YesNo
May we leave a message on your answering machine at home or on your cell phone?*

YesNo
May we discuss your Medical condition with other members of your family? If Yes, please include all names allowed:*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*
Should be Empty:

New Patient Intake Form