• New Patient Medical & Health History Form

    New Patient Medical & Health History Form

  • This form will ask about your health history, including your medications, allergies, medical and surgical history, family and psychiatric history, social background, and more. We’ll also ask for your primary care doctor’s contact info and a few basic demographic details to verify your identity.

    Before you start, please grab your pill bottles (including vitamins and supplements) and have your pharmacy’s name, phone number, and address ready. We don’t send prescriptions to local CVS pharmacies (sorry — no exceptions), and we can’t send to mail-order pharmacies at your first visit. Also, 90-day prescriptions won’t be approved unless you’ve been stable on your dose with us for at least two months.

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Patient's SS#*
  • Mobile Phone*
  • How did you hear about our practice?
  • Picture of Your Drivers License or State ID to verify identity*
  • Take a Selfie for our Medical Records*
  • Biological Sex*
  • Gender Identity*
  • Emergency Contact Phone*
  • Primary Care Clinician Phone Number

  • Reason for Visit

  • What is the main concern related to this visit?*

  • Medical & Surgical History

  • Past Medical History*
  • Past Surgical History*
  • Most Recent height and weight
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  • Ob/Gyn History:

  • Intention of Pregnancy*

  • Psychiatric History

  • Have you ever been hospitalized for mental health?
  • List your psychiatric hospitalizations. Include psychiatric inpatient stays for mental health reasons. Examples: suicidality, mania, psychosis, detox/rehab, eating disorders). Do NOT list ER visits, medical admissions, surgeries, or childbirth.*
  • Have you ever had a suicide attempt?*
  • List your suicide attempts:*
  • Have you ever been diagnosed with any of the following?*
  • PAST medications:*
  • Do you currently have a therapist?*
  • Most recent psychiatrist (or other mental health clinician)*
  • Have you ever been to a long-term treatment facility?*
  • Have you ever been treated with any of the following modalities?*

  • Allergy and Medication History

  • Do you have any medication allergies?*
  • Allergy Details:
  • List *ALL* Current prescribed medications (include oral contraceptive, if applicable):*
  • List *ALL* Current vitamins, herbs, and supplements. If none, state none*

  • Family History

  • Has any family member or relative died of heart problems and/or sudden death prior to age 35?*
  • Father
  • Mother
  • Family History
    Rows

  • Social History

  • Substances:

  • Which tobacco products do/did you use?*

  • Home/Personal:

  • Personal Care*
  • Sexual activity*
  • Current Method of Birth Control*

  • Education/Employment

  • Military Service*

  • Signature and Submission

  • Who is completing this form?
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  • Signature*
  • Today's Date:*
     / /
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: