Chronos Clinic — New Patient Intake

Chronos Clinic — New Patient Intake

Complete this confidential intake before your visit; don’t use it for emergencies—call 911. Fields marked with * are required.
Patient Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Name
Pronouns
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Primary Care Physician
Preferred Pharmacy
Height and Weight
What Brings You In — Your Goals
Main reason for your visit
What sport, activity, or goal matters most right now?
Is there a specific event or timeline?
What would a good outcome look like?
Primary areas of interest
Current Symptoms
Areas currently bothering you

Other
Describe the main problem
How long has this been going on?
Pain at its worst

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain imaginable
What makes it better or worse?
Orthopedic & Injury History
Prior injury to the affected area?
If yes, describe the injury
Previous surgeries — type, joint, and year
Recent imaging completed?
If Yes, X-ray, MRI, CT, and/or Ultrasound? When and where was it done?
Regenerative, Peptide, & Longevity History
Are you currently using any peptides?
If yes, please list the peptide(s), dose, duration of use, and source
Have you had PRP, prolotherapy, stem cells, or other biologic injections?
Are you currently on hormone therapy or TRT?
Current supplements — name and dose
Medical History
Medical conditions you have been diagnosed with

Other
Other medical conditions not listed above
Cancer History & Screening
Personal history of cancer?
If yes, cancer details
Any active or suspected cancer now?
Family history of cancer?
If yes, family cancer details
Up to date on age-appropriate cancer screening?
Medications
List all prescription medications, including name and dose
Do you take a blood thinner or anticoagulant such as aspirin, warfarin, Eliquis, or Plavix?
Do you take a GLP-1 medication such as Ozempic, Wegovy, Mounjaro, or Zepbound?
If yes, please list the dose and last dose taken
Do you use oral or injected steroids?
Allergies
List Medication and/or other Allergies, and Reaction
For Patients Who Can Become Pregnant
Currently pregnant?
Breastfeeding
Trying to conceive
Treatment Modality Safety Screen
Do you have a pacemaker, defibrillator, or other implanted electronic device?
Do you have metal implants or hardware near the area to be treated?
Do you have an active infection or open wound over the area to be treated?
Do you have a current or recent blood clot (DVT)?
Do you have epilepsy or a seizure disorder?
Lifestyle & Optimization Baseline
Activity level
Typical weekly exercise type
Typical weekly exercise days per week
Occupation
Physical demands of occupation
Tobacco or nicotine use
Alcoholic drinks per week
Average sleep hours per night
Sleep quality
Nutrition rating
Stress level
Labs
Have you had blood work done in the last 6 months?
Would you be willing to complete a baseline lab panel if recommended?
Anything Else
Anything else you want Dr. Rahman to know?
How did you hear about Chronos?
Acknowledgments & Consent
I understand this visit is cash-pay and will not be billed to insurance.
I understand that a clinical evaluation is required and that separate consent is needed for any specific treatment.
I acknowledge understanding of the Notice of Privacy Practices (HIPAA) and understand how my health information may be used and disclosed.
If my visit is conducted by telemedicine, I consent to evaluation and care by telemedicine.
I consent to Chronos Clinic contacting me by email, phone, or text about my care and appointments.
Typed full name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Chronos Clinic — New Patient Intake

Patient Information

What Brings You In — Your Goals

Current Symptoms

Orthopedic & Injury History

Regenerative, Peptide, & Longevity History

Medical History

Cancer History & Screening

Medications

Allergies

For Patients Who Can Become Pregnant

Treatment Modality Safety Screen

Lifestyle & Optimization Baseline

Labs

Anything Else

Acknowledgments & Consent