Doctor LeTa Initial Paperwork

Demographics and Contact Information
First Name
Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Place of Birth
Occupation
Height
Weight
Pronouns
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referred by
Gender at Birth
Ethnicity

Other
Medical History and Current Health
Current health concerns or ongoing medical problems
Please describe any other current symptoms or concerns
List all current medications
List all vitamins, supplements, and herbs
List all medications you are allergic to
Describe your reaction to each medication allergy
List all food allergies
Describe your reaction to each food allergy
List all environmental allergies
Describe your reaction to each environmental allergy
Did you have frequent ear infections as a child?
Did you have frequent throat infections as a child?
Did you have frequent colds as a child?
Did you have chickenpox as a child?
Did you have measles as a child?
Did you have mumps as a child?
Did you have rubella as a child?
Did you have rheumatic fever as a child?
Did you have scarlet fever as a child?
Did you have whooping cough as a child?
Did you have polio as a child?
Did you have childhood asthma?
Please list any other childhood illnesses or conditions
Have you ever been hospitalized?
If yes, please list hospitalizations and dates
Have you ever had surgery?
If yes, please list surgeries and dates
Have you taken antibiotics within the past 12 months?
If yes, please list the antibiotics and dates
Do you follow a special diet?
If yes, please describe your diet
Do you have any food intolerances?
If yes, please describe your food intolerances
How often do you have bowel movements?
Do you have constipation?
Do you have diarrhea?
Do you have abdominal pain?
Do you have blood in your stool?
Do you have black or tarry stools?
Do you have hemorrhoids?
Do you have nausea or vomiting?
Please describe any other bowel or digestive concerns
Do you have trouble urinating?
Do you have frequent urination?
Do you have painful urination?
Do you have urinary urgency?
Do you have urinary frequency at night?
Do you have blood in your urine?
Do you have urinary incontinence?
Do you have bladder infections?
Please describe any other urinary concerns
Do you have pelvic pain or pressure?
Do you have vaginal discharge?
Do you have vaginal itching or irritation?
Do you have painful intercourse?
Do you have irregular bleeding?
Please describe any other pelvic or gynecologic concerns
Do you smoke cigarettes?
If yes, how many cigarettes per day?
Do you use vaping products?
If yes, how often do you vape?
Do you use alcohol?
If yes, how many drinks per week?
Do you use recreational drugs?
If yes, please describe the substances used and frequency
Have you been exposed to secondhand smoke?
Have you been exposed to chemicals or fumes at work?
Have you been exposed to asbestos, silica, or dust?
Have you been exposed to mold or mildew?
Have you been exposed to animals or pets?
Have you been exposed to sick contacts?
Please describe any other environmental exposures
How often do you exercise?
What type of exercise do you do?
How long is each exercise session?
Do you feel stressed most days?
Do you have a good support system?
Do you live alone?
Please describe your living situation
Are you currently employed?
What is your occupation?
Have you experienced recent major life changes?
If yes, please describe the changes
Have you ever been treated for depression?
Have you ever been treated for anxiety?
Have you ever been treated for bipolar disorder?
Have you ever been treated for attention deficit disorder?
Have you ever been treated for schizophrenia or psychosis?
Have you ever been treated for an eating disorder?
Have you ever been treated for post-traumatic stress?
Have you ever been treated for substance use disorder?
Please list any other mental health diagnoses or treatment
Do you currently feel depressed?
Do you currently feel anxious?
Do you have trouble sleeping?
Do you have nightmares or flashbacks?
Have you had thoughts of hurting yourself?
Have you had thoughts of hurting others?
Are you sexually active?
Partners
Do you have sex with men?
Do you have sex with women?
Do you use condoms?
Do you use other forms of birth control?
If yes, please describe your birth control method
Have you ever had a sexually transmitted infection?
If yes, please list the infection(s)
Do you have any sexual concerns you would like to discuss?
If yes, please describe your concerns
Men/Women Only Sections and Administrative Acknowledgments
Male-specific section acknowledgement
Signature
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Demographics and Contact Information

Medical History and Current Health

Men/Women Only Sections and Administrative Acknowledgments