New Patient Intake

New Patient Intake

Please complete this health history questionnaire to the best of your abilities prior to your appointment. Your surgeon will review your responses. Your Protected Health Information is secure on this intake form. If you do not have an appointment yet, please call 707-938-7690. Thank You! --Dr Alexis and Dr Kidd
Personal Information

Contact Info, Demographics, Emergency Contacts
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*

FemaleMaleNon-binaryTrans FemaleTrans MaleOther
Email*
example@example.com
Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address, if different from home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Insurance Information*
Plan Name **Please copy this information directly from your insurance card, or upload a picture below. Please be as specific as possible!**
ID number
Group Number
Effective Date
Medical Group Name, if applicable
Additional information from your insurance card:
Please include any additional information from your card here.
Secondary Insurance Information
Supplemental Plan Name. **Please be specific**
ID number
Group Number
Effective Date
Additional information from your insurance card:
Please include any additional information from your card here.
If you can, please upload a copy of your insurance cards, front and back:

A smartphone snapshot works fine!
Cancelof
Emergency Contact Name*

First NameLast Name
Relationship
Emergency Contact Phone Number
Primary Care Physician

First NameLast Name
Pharmacy
Where can Dr Alexis leave you a detailed message regarding results?*

Phone, as listed aboveE-mail, as listed aboveNeitherOther, list here
Your Health Information

Past Medical and Surgical History
Why are you seeing the surgeon today?*
Body Measurements:*
Please list your Allergies:
Have you ever had, or, are you being treated for:*
Any other medical conditions?
Please list Operations or Major Procedures you have had:
Please list your Current Medications, including DOSE (how much) and FREQUENCY (how many times per day). If you take no medications, please list "NONE"*
Have you had a colonoscopy before?
If yes, when?
Results?
Women, are you?

Pre-menopausalPeri-menopausalPost-menopausal, naturalPost-menopausal, surgicalOther
Age at Menarche (first period)
Age at Menopause
Number of Pregnancies
Number of Births
Age at First Birth
Your Health Habits

Social History
Do you use Alcohol?*
If yes, how many drinks per WEEK
Do you use Tobacco?*
If yes, how many cigarettes (or equivalent) per DAY
Do you use Marijuana?
Additional Comments
Your Family Medical History

Has anyone in your family had cancer or a precancerous condition? Please share age at diagnosis and any other details in the text box below.

	Mother	Father	Sibling	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
Breast Cancer
Ovarian Cancer
Colorectal Cancer
Colorectal Polyps
Pancreatic Cancer
Other Cancers (please describe below)

What other diseases run in your family?
Click here if family history is UNKNOWN

Unknown family history
Review of Systems

Please check if you a CURRENTLY having trouble with any of the following: (Check all that apply)
General

Weight lossFever/ChillsFatigue/MalaiseOther
Eyes

Vision changesDischargeEye painOther
Ears, Nose, Throat

EaracheHearing lossNosebleedsSore ThroatOther
Heart, Vascular

Chest painPalpitationsFaintingPainful breathing with exercisePain in legs with exerciseSwelling of arms/legsOther
Respiratory

CoughTrouble breathingSpitting up bloodWheezingOther
Gastrointestinal

Nausea or VomitingTrouble swallowing, food getting "stuck"Diarrhea, more than 6 loose stools per dayConstipationBlood in the stool, redBlack stoolsYellow skin, jaundiceChange in bowel habitsAnal PainPerianal itching or irritation of the skin at the anusOther
Genitourinary

Painful urinationBlood in the urineAbnormal menstrual bleedingIncontinencePelvic painOther
Musculoskeletal

Back painJoint painJoint swellingMuscle weaknessOther
Skin

RashExcessive drynessSuspicious lesionOther
Neurologic

ParalysisNumbnessVertigoPassing outSeizureOther
Psychiatric

DepressionAnxietyMemory lossSuicidal ideationOther
Endocrine

Heat or cold intoleranceWeight lossExcessive thrist, hungerLethargyOther
Heme/Lymphatic

Abnormal bruising or bleedingEnlarged lymph nodesBlood clotsOther
Allergy/Immunologic

ItchingHay feverHIV exposurePersistent infectionsOther
If you are OVER 65 years old, have you established an ADVANCE CARE PLAN and/or identified a Surrogate Decision Maker?
Advance directives are designed to respect patient’s autonomy and determine their wishes about future life-sustaining medical treatment if they become unable to indicate their wishes. Advanced Care Planning includes Advanced Directives, Living Wills, POLST Forms, naming a health care proxy or Durable Power of Attorney for Health care, etc.
Thank you! Now, here is the fine print...

Please take a moment to review the policies below and indicate your acceptance. You do not need to print these forms. Your e-signature below indicates that you have READ the policies and ACCEPT the terms, including our "No-show"/cancellation FEES and billing/collections policies. ***Ensure all items with a red asterisk are completed to complete your intake form.***
e-Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake

Personal Information

Your Health Information

Your Health Habits

Your Family Medical History

Review of Systems

Thank you! Now, here is the fine print...