New Patient Intake Form

Patient Intake Form

Please complete all information on your patient intake questionnaire prior to your consultation to avoid any delays in processing your treatment plan.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Height
Weight
Sex
Gender Identity
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Delivery Instructions
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Occupation
Emergency Contact Name

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

Please upload a copy of your ID
Cancelof

Patient Intake Form

Medical Questions
HRT/PeptidesKetamine TherapyMedical Weight Loss
What symptoms are you currently experiencing? Please describe and their duration.
What are your treatment goals?
What are your current stressors?
Current Medications and Supplements
Prescription Medications
Non-Prescription Medications and Supplements

Rows	Yes	No
Do you feel helpless/hopeless?
Have you ever attempted suicide or intentionally harmed yourself?
Do you have a suicidal plan?
Do you have means to carry out your plan?

Patient Intake Form

Rows	Not at all	Several days	More than 1/2 the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite of overeating
Feeling bad about yourself- or that you are a failure or have let yourself or family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
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.
Thoughts that you would be better off dead or of hurting yourself in some way.
Feeling nervous, anxious, or on edge
Not being able to stop of control worrying
Worrying to much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen