New Member Dossier
This dossier establishes a thoughtful clinical baseline so care can be tailored precisely to you. It helps our team understand history, risk, lifestyle, priorities, and preventive needs in a way that supports high- touch ongoing care. This document is not for emergencies.
HOW TO COMPLETE
Answer each section as completely as you can. If you do not know a detail, leave it blank and we will review it together.
SECURE UPLOADS
Use the secure upload area in your intake link to send labs, consult notes, imaging reports, hospital records, or advance directives.
MEMBER IDENTIFICATION
Member name
Date completed
-
Month
-
Day
Year
Date
Preferred phone
Format: (000) 000-0000.
Preferred email
example@example.com
Voicemail allowed
Yes
No
Text message allowed
Yes
No
Email allowed
Yes
No
Portal messages allowed
Yes
No
SECURE UPLOAD REMINDER
Please use the secure upload area in your intake link to send photo ID, insurance cards, medication lists, recent labs, imaging reports, consultant notes, hospital records, or advance directive documents.
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SECTION 01
Member Profile
Identity, contact details, pharmacy, prior primary care, and records background.
IDENTITY
Name
First Name
Middle Initial
Last Name
Date of birth
Preferred name
Pronouns
CONTACT
Mobile phone
Format: (000) 000-0000.
Alternate phone
Format: (000) 000-0000.
Email address
example@example.com
Home address
City
State / ZIP
INSURANCE AND PHARMACY
Primary insurance
Member / ID number
Secondary insurance
Member / ID number
Preferred pharmacy
Pharmacy phone / address
MAMBA PHYSICIAN CARE
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SECTION 02
Care Coordination
Prior care, emergency contact, authorized contacts, specialists, and support logistics.
PRIOR PRIMARY CARE AND RECORDS
Previous PCP / clinic
Phone / fax if known
Date of last physical
-
Month
-
Day
Year
Date
Date of last labs
-
Month
-
Day
Year
Date
Recent imaging, testing, or consultant reports and where completed
If you have recent cardiology, GI, oncology, hospital, imaging, or specialist reports, please use the secure upload area in your intake link.
EMERGENCY CONTACT
Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
AUTHORIZED CONTACTS (HIPAA)
AUTHORIZED CONTACTS (HIPAA)
Rows
Name
Relationship
Phone / Email
Discuss
Schedule
1
2
3
4
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CARE COORDINATION
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SECTION 03
Specialists and Support
Consultants you see, support needs, and primary concerns.
CONSULTANTS AND SPECIALISTS
CONSULTANTS AND SPECIALISTS
Rows
Physician / clinic
Specialty
Reason seen
Phone / location
1
2
3
4
Please securely upload important records such as consult notes, procedure reports, discharge summaries, or imaging reports when available.
SUPPORT LOGISTICS
Who helps you if you are sick or need support at home?
Anything that could make it difficult to follow through with care because of transportation, work, caregiving, or schedule?
PRIMARY CONCERNS AND GOALS
What would you like us to focus on first?
What would a "win" look like in the next 90 days?
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SECTION 04
Clinical Baseline
Diagnoses, current conditions, cancer history, and treated conditions.
DIAGNOSES AND CURRENT CONDITIONS
Rows
Condition / diagnosis
Year diagnosed
Notes
1
2
3
4
5
6
7
CANCER HISTORY OR TREATED CONDITIONS
Rows
Condition / cancer
When
Treatment / surgery / remission details
1
2
3
4
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SECTION 05
Major Medical Events
Hospitalizations, surgeries, allergies, and major prior events.
HOSPITALIZATIONS, SURGERIES, AND MAJOR EVENTS
HOSPITALIZATIONS, SURGERIES, AND MAJOR EVENTS
ICU admission
Intubation / ventilator
Major anesthesia complication
ER / urgent care / hospital stay in last 12 months
ER / urgent care / hospital stay in last 12 months
Rows
Event / procedure
Year
Facility
Outcome / notes
1
2
3
4
5
ALLERGIES AND INTOLERANCES
ALLERGIES AND INTOLERANCES
No known allergies
Seasonal
Medication
Food
Latex
ALLERGIES AND INTOLERANCES No known allergies Seasonal Medication Food Latex
Rows
Allergen / medication
Reaction
Severity
1
2
3
4
5
6
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SECTION 06
Medications and Supplements
Prescription medications, supplements, and medication follow-through.
PRESCRIPTION MEDICATIONS
Rows
Medication
Dose
Frequency
How long
Notes
1
2
3
4
5
6
SUPPLEMENTS, VITAMINS, AND OVER-THE-COUNTER PRODUCTS
Rows
Product
Dose
Frequency
How long
Notes
1
2
3
4
5
6
Do you ever miss medications because of cost, side effects, travel, forgetfulness, or schedule?
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Family and Sexual Health
Relevant family history plus sexual health background.
FAMILY HISTORY
Please include only mother, father, sister, brother, maternal grandparents, and paternal grandparents.
Unknown / adopted
No significant family history known
FAMILY HISTORY Please include only mother, father, sister, brother, maternal grandparents, and paternal grandparents. Unknown / adopted No significant family history known
Rows
Relative
Condition(s)
Age at diagnosis / notes
1
2
3
4
5
6
7
8
Helpful conditions to include: heart disease, stroke, diabetes, high blood pressure, high cholesterol, cancers, autoimmune disease, dementia, or other major hereditary concerns.
GENERAL SEXUAL HEALTH
Sexually active
Interested in STI screening
History of STI(s)
Relations with males, females, both, or other
Protection or contraception strategy
Any concerns you would like us to evaluate
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SECTION 08
Male and Female Health
Male-specific and female-specific review.
MALE HEALTH
Erectile dysfunction or change in sexual function
Low libido or low drive
Urinary issues, weak stream, urgency, or nighttime urination
Known prostate issues or prior evaluation
Testicular pain, swelling, or prior concerns
Any male-specific concern you want reviewed
FEMALE HEALTH
Pregnancies (total number)
Children (number)
Heavy bleeding, irregular periods, or significant cramping
Typical duration of menstrual cycle / bleeding
Menopause, perimenopause, or hormone-related concerns
Any gynecologic issue you want reviewed
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SECTION 09
Lifestyle Foundations
Daily context, stressors, sleep, and nutrition.
DAILY CONTEXT
Occupation and typical schedule
Primary stressors right now
Support system
Travel, caregiving, work, or home constraints
SLEEP AND RECOVERY
Average sleep hours per night
Sleep quality (1-10)
Snoring, pauses in breathing, or sleep concern
Prior sleep study completed
CPAP or other sleep treatment
What helps your sleep / what disrupts it
NUTRITION AND HYDRATION
Diet pattern
Caffeine: type and servings per day
Water intake per day
Food sensitivities or preferences
Typical day of eating
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SECTION 10
Mental Health and Daytime Alertness
Brief symptom review plus complete daytime sleepiness scale.
PAST 2 WEEKS
PAST 2 WEEKS
Rows
Not at all
Several days
More than half
Nearly daily
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
History of therapy or counseling
History of psychiatric medication
What helps you cope when stress is high?
Any safety concerns today
DAYTIME SLEEPINESS SCALE
For each situation, select how likely you are to doze off during the day. 0 = never, 1 = slight, 2 = moderate, 3 = high likelihood. Higher total scores may suggest poor sleep quality or sleep disorders.
DAYTIME SLEEPINESS SCALE
Rows
0 Never
1 Slight
2 Moderate
3 High
Sitting and reading
Watching TV
Sitting inactive in a public place
Passenger in a car for an hour
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
In a car, while stopped in traffic
Total score (0-24)
Additional notes
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SECTION 11
Activity, Alcohol, and Substances
Exercise, nicotine, alcohol use, CAGE questions, and recreational substances.
TRAINING AND ACTIVITY
Exercise days per week
Type of exercise or sport
Injuries or limitations
Recovery practices
Sedentary hours per day
Step count if known
TOBACCO AND NICOTINE
Include cigarettes, vaping, cigars, chewing tobacco, or nicotine pouches. Note frequency and duration if applicable.
Status and type (never, former, current; cigarettes, vape, cigars, chew, pouches)
Quit year
Packs or use per day
Years used
ALCOHOL USE
Do you drink alcohol
Typical drinks per week
Type: beer, wine, spirits, cocktails
Heavier occasions (for example: 4+ drinks in one sitting for women or 5+ for men)
TRAINING AND ACTIVITY
Rows
Yes / No
Have you ever felt you should drink less?
Have comments about your drinking ever bothered you?
Have you ever felt regret or guilt about drinking?
Have you ever needed a morning drink to feel steady or relieve a hangover?
RECREATIONAL SUBSTANCES
Include cannabis or other substances. Note type, frequency, and any concerns you would like addressed. Never, former, occasional, or regular; type(s), frequency, and notes
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SECTION 12
Preventive Screening
Preventive screening history and key testing completed to date.
PREVENTIVE SCREENING
PREVENTIVE SCREENING
Rows
Most recent date
Findings / notes
Colorectal screening
Mammogram
PAP / cervical screening
Skin cancer screening
Eye exam
Dental exam
Sleep study
Coronary calcium score
Cardiac stress test
Other
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SECTION 13
Key Labs and Testing
Expanded laboratory values and diagnostic testing.
KEY LABS
Metabolic · Lipids · Renal · Hormonal
KEY LABS Metabolic Lipids - Renal - Hormonal
Rows
Value
Date
A1C
LDL
HDL
Triglycerides
Creatinine
TSH
Vitamin D
Total Testosterone
Free Testosterone
Other
ADVANCED / DIAGNOSTIC TESTING
ADVANCED / DIAGNOSTIC TESTING
Rows
Date
Notes
DEXA Scan
Coronary Calcium Score
Cardiac Stress Test
Sleep Study
Other
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SECTION 13
Immunization Review
Expanded vaccination and immunization tracking.
VACCINES AND IMMUNIZATION REVIEW
Do you believe you received routine childhood vaccines?
Any vaccine concerns or reactions worth noting
VACCINES AND IMMUNIZATION REVIEW
Rows
Status / Date
Notes
Tetanus / Tdap
Influenza
COVID
Shingles
Pneumococcal
RSV
Hepatitis A
Hepatitis B
HPV
MMR
Varicella
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SECTION 13
Vitals and Baseline Metrics
Baseline metrics and core measurements.
VITALS
VITALS
Rows
Value
Date
Height
Weight
Blood Pressure
Waist Circumference
BMI
Other
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SECTION 14
Health Maintenance and Safety
Daily function, safety, exposures, and ongoing care barriers.
DAILY FUNCTION AND SAFETY
Any falls in the last 12 months? Any injury?
Any change in hearing or vision?
Do you use glasses, contacts, hearing aids, cane, walker, or other support devices?
Access to firearms in the home or regular environment
Any home safety concern you want us to know about
Memory, concentration, or cognition concerns
HEALTH MAINTENANCE REVIEW
Any major exposure concerns at home, work, or travel (chemical, dust, mold, pets, water damage, etc.)?
Anything that could make it difficult to follow through with care because of transportation, finances, work, travel, or caregiving?
Any performance, longevity, or quality-of-life goals you want to prioritize?
Anything else that would help us understand your day-to-day health picture?
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HEALTH MAINTENANCE AND SAFETY
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SECTION 15
Goals of Care and Advance Planning
Advance directives, surrogate information, and treatment preferences if seriously ill.
GOALS OF CARE AND ADVANCE PLANNING
Living will
Health care power of attorney
Surrogate decision maker
Best phone number for surrogate
Format: (000) 000-0000.
GOALS OF CARE AND ADVANCE PLANNING
Rows
Yes
No
Unsure / Discuss
CPR / chest compressions
Breathing tube / ventilator
Non-invasive ventilation (BiPAP / CPAP support in hospital)
ICU-level care
Hospital transfer if condition worsens
Comfort-focused care if recovery is unlikely
Current code status (if known)
Full Code
DNR
DNI
Limited DNR
Unsure / discuss
If you already have a living will, advance directive, DNR, or power-of-attorney document, please upload it securely through your intake link.
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GOALS OF CARE AND ADVANCE PLANNING
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SECTION 16
Final Acknowledgement and Signature
Final review, acknowledgements, and signature for your chart.
ACKNOWLEDGEMENTS
I confirm the information provided is accurate to the best of my knowledge.
understand this dossier is not for emergencies.
I authorize Mamba Physician Care to coordinate with my listed pharmacies, consultants, and facilities as needed.
I consent to communication through the channels selected above, understanding that standard message security may vary.
SIGNATURE
Member signature
Date
-
Month
-
Day
Year
Date
Printed name
Best callback number
Format: (000) 000-0000.
MAMBA PHYSICIAN CARE
FINAL ACKNOWLEDGEMENT AND SIGNATURE
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