• Chronic Condition Management Intake

  • Welcome to Simone RX. Ongoing care designed to support your long-term health and wellness. Managing chronic health conditions should feel organized, supportive, and accessible. Our provider-led chronic care program is designed to help patients maintain continuity of care, monitor ongoing conditions, and receive personalized treatment support through a modern telehealth experience. Whether you are managing high blood pressure, diabetes, thyroid concerns, high cholesterol, or other ongoing medical conditions, our goal is to help simplify your care while supporting better long-term health outcomes. Most intakes take approximately 5–10 minutes.
  • Confidential intake — please complete each section accurately.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Preferred Communication*
    • new content block 

  • Health Goals & Conditions

  • Which Condition(s) Would You Like Help Managing? (Check all that apply)*
  • What Are Your Main Health Goals? (Check all that apply)*

  • Current Treatment Information

  • Do you have any medication allergies?*

  • Recent Medical Care (Past 6 Months)

  • Have you been hospitalized in the past 6 months?*
  • Have you visited the emergency room or urgent care in the past 6 months?*
  • Have you had recent blood work or diagnostic testing?*

  • Home Monitoring

  • Do You Monitor Any of the Following at Home? (Check all that apply)*

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  • Pharmacy Information

  • Format: (000) 000-0000.

  • Consent & Acknowledgment

  • Should be Empty: