New Patient Assessment
Proximity Wellness. LLC
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Marital Status
Single
Married
Separated
Divorced
Widowed
Gender Assigned at Birth
*
Male
Female
Name of Primary Care Provider (leave blank if not applicable)
Prefix
First Name
Last Name
Suffix
When was your last visit with your primary care provider (if applicable)
-
Month
-
Day
Year
Date
In as much detail as you can provide- please describe your current concern
*
How long have you had this concern?
*
Please list any medications and/or supplements you are currently taking (if none, list "none" below).
*
Please enter your current height and weight in the fields below:
*
Please tell us about any current or previous health concerns (example: cancer, high blood pressure, diabetes, etc.).
*
Are there any medical or mental health concerns that run in your family?
*
Do you use caffeine, alcohol, or nicotine? (if yes, describe below)
*
Do you use any recreational substances? (marijuana, cocaine, etc.).
*
Front Side of ID or Driver's License
*
Face photo (selfie) to verify to ID
*
Patient Consent to Treat
*
Patient attests that they have reviewed and agree with the Consent to Treat Policy
Continue
Continue
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