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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 Name
Middle Name
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
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Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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2007
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Female
Male
Non-binary
Trans Female
Trans Male
Other
Email
*
example@example.com
Phone Number
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address, if different from home address
Street Address
Street Address Line 2
City
State / 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:
Browse Files
Drag and drop files here
Choose a file
A smartphone snapshot works fine!
Cancel
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Emergency Contact Name
*
First Name
Last Name
Relationship
Emergency Contact Phone Number
Primary Care Physician
First Name
Last Name
Pharmacy
Where can Dr Alexis leave you a detailed message regarding results?
*
Phone, as listed above
E-mail, as listed above
Neither
Other, 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?
Please Select
Yes
No
If yes, when?
Results?
Women, are you?
Pre-menopausal
Peri-menopausal
Post-menopausal, natural
Post-menopausal, surgical
Other
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?
*
Please Select
No
Yes
If yes, how many drinks per WEEK
Do you use Tobacco?
*
Please Select
No, never
No, quit more than 1 year ago
No, quit within the last year
Yes, currently I use tobacco
If yes, how many cigarettes (or equivalent) per DAY
Do you use Marijuana?
Please Select
No, never
Yes, daily
Yes, weekly
Rarely, or less than once a month
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 loss
Fever/Chills
Fatigue/Malaise
Other
Eyes
Vision changes
Discharge
Eye pain
Other
Ears, Nose, Throat
Earache
Hearing loss
Nosebleeds
Sore Throat
Other
Heart, Vascular
Chest pain
Palpitations
Fainting
Painful breathing with exercise
Pain in legs with exercise
Swelling of arms/legs
Other
Respiratory
Cough
Trouble breathing
Spitting up blood
Wheezing
Other
Gastrointestinal
Nausea or Vomiting
Trouble swallowing, food getting "stuck"
Diarrhea, more than 6 loose stools per day
Constipation
Blood in the stool, red
Black stools
Yellow skin, jaundice
Change in bowel habits
Anal Pain
Perianal itching or irritation of the skin at the anus
Other
Genitourinary
Painful urination
Blood in the urine
Abnormal menstrual bleeding
Incontinence
Pelvic pain
Other
Musculoskeletal
Back pain
Joint pain
Joint swelling
Muscle weakness
Other
Skin
Rash
Excessive dryness
Suspicious lesion
Other
Neurologic
Paralysis
Numbness
Vertigo
Passing out
Seizure
Other
Psychiatric
Depression
Anxiety
Memory loss
Suicidal ideation
Other
Endocrine
Heat or cold intolerance
Weight loss
Excessive thrist, hunger
Lethargy
Other
Heme/Lymphatic
Abnormal bruising or bleeding
Enlarged lymph nodes
Blood clots
Other
Allergy/Immunologic
Itching
Hay fever
HIV exposure
Persistent infections
Other
If you are OVER 65 years old, have you established an ADVANCE CARE PLAN and/or identified a Surrogate Decision Maker?
Please Select
No, I don't have one and am not interested.
No, I don't have one, but will discuss with my primary care physician.
Yes, I have an Advanced Directive (or equivalent) at my primary care physician's office and/or at the Hospital.
Yes, I have an Advanced Directive (or equivalent) at my home.
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.***
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