New Patient Information
Name
*
First Name
Last Name
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security Number
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.
Payment Information
Primary Insurance Company
*
Please Select
Amerigroup
United Healthcare Community Plan
Medicare
Aetna
Blue Cross Blue Shield
Cigna
Humana
Tricare
Other
No insurance
Primary Insurance Group Number
Primary Insurance Member ID Number
Secondary Insurance Company
*
Please Select
Amerigroup
United Healthcare Community Plan
Medicare
Aetna
Blue Cross Blue Shield
Cigna
Humana
Tricare
Other
No insurance
Primary Insurance Group Number
Primary Insurance Member ID Number
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Emergency Contacts
The state of Tennessee requires that all patients provide the names, addresses and phone number for two emergency contacts. These people will only be contact if we are concerned that your life or safety may be in danger.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
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Addiction Symptoms
Please answer the following questions considering the period of time when you were having problems using opioid drugs / heroin.
Were you using opioid drugs in larger and large amounts?
*
Yes
No
Did you desire to stop using, but were unable to do so?
*
Yes
No
Did you spend a significant amount of time obtaining opioid drugs?
*
Yes
No
Did you have cravings or desires to use opioid drugs?
*
Yes
No
Did your use of these drugs make it so that you were unable to fulfill your obligations?
*
Yes
No
Did your use of these drugs cause you personal, professional or legal problems?
*
Yes
No
Did you give up activities due to your use of opioid drugs?
*
Yes
No
Did your use of opioid drugs result in you being in physically hazardous situations (around people with weapons, driving to bad areas of town, driving under the influence of drugs)?
*
Yes
No
Did you continue to use opioid drugs despite the problems that your use may have caused?
*
Yes
No
Did you develop a tolerance to opioid drugs (a need for greater amounts of drugs to achieve the desired effect)?
*
Yes
No
Did you have withdrawal symptoms if you did not use drugs on a routine basis?
*
Yes
No
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History
Why do you want to be seen?
*
Treatment of pain pill / heroin addiction
Treatment of alcohol addiction
Treatment of cocaine / methamphetamine addiction
Treatment of tobacco addiction
Treatment of other addiction(s)
Treatment of mental health problems
Other
Heading
Tell us about the history of this problem (when it began, how it has progressed, treatments you have tried, etc.)
What treatments have you tried in the past? (Please pick all that apply.)
12 Step Groups (NA, AA, Celebrate Recovery, etc.)
Vivitrol / Naltrexone
Methadone
Suboxone
Inpatient Treatments
Intensive Outpatient Treatments
Counseling
Other
On what date did you last use opiates / heroin / Suboxone?
 -
Month
 -
Day
Year
Date
How many years has this been a problem for you?
Why did you begin using? (Please pick all that apply.)
Recreational use
Prescribed by a physician
Self treatment of depression / anxiety or other problems
Other
Longest period of time not using drugs / alcohol?
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Which of the following have you used in the past?
How many packs per day do you smoke?
How many times have you overdosed?
How much money do you spend every day on your drug habit?
Do you have any 'process addictions'? (Please pick all that apply.)
Gambling
Internet
Shopping
Sex
Gaming
Other
Do you have any of the following illnesses? (Please pick all that apply.)
Opiate Use Disorder
Alcohol Use Disorder
Stimulant Use Disorder (cocaine / methamphetamine)
Sedative Use Disorder (benzodiazepine)
Tobacco Use Disorder
Anxiety
Depression
Bipolar Disease
Post Traumatic Stress Disorder
Obesity
Diabetes
Thyroid Disease
High Blood Pressure
High Cholesterol
Heart Disease
Stroke
Cancer
Heartburn
Constipation
Nausea
Asthma
COPD / Emphysema
Urinary problems
Gynecologic problems
Backpain / back problems
Muscle problems
Sleep problems
No medical problems
Other
Have you had any surgeries? (Please pick all that apply.)
Ear surgery (including tubes as a child)
Eye surgery (cataracts, etc.)
Tonsillectomy
Thyroid surgery
Throat surgery
Lung surgery
Heart surgery
Bowel surgery
Hysterectomy (removal of uterus)
Oophorectomy (removal of ovary / ovaries)
Orthopedic surgery (bone or joint surgery)
D&C
Tubal Ligation
Vasectomy
Other
Which medications and dosages are you taking? Please list all of them prescribed by your doctor.
Which over the counter medications and dietary supplements are you taking? Please list all of them.
What allergies do you have? Please list all of them.
Childhood illnesses? (Please pick all that apply.)
Chickenpox
Measles
Pneumonia
Mumps
Rubella
Other
Are you up to date on your vaccinations?
Yes
No
Unknown
Who is your primary care physician?
How do we contact your primary care physician?
When did you have your last annual exam?
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Family Medical History
Did your father have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
Did your mother have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
Did your brothers or sisters have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
Did your maternal (mother) grandparents have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
Did your paternal (father) grandparents have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
Did your children have any of the following illnesses? (Please pick all that apply.)
Alcohol Use Disorder
Drug Use Disorder (any drugs - legal or illegal)
Diabetes
Heart Disease
Stroke
Asthma
Blood clotting problems
Cancer
Depression
Anxiety
Bipolar Disease
Unknown
Other
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Social History
What is your marital status?
Please Select
Single
Married
Significant other
Divorced
Widowed
Other
Submit
Where do you live?
Please Select
House (owned by myself)
House (rented)
Trailer
Apartment
Hotel
Halfway house
Homeless
How many people live with you?
Do any of these people use drugs / alcohol?
Yes
No
Other
Have you ever been abused? (Please pick all that apply.)
Physically (hit, slapped, etc.)
Emotionally (made to feel 'stupid' or bad about yourself, yelled at, etc.)
Sexually (forcibly made to engage in sexual acts)
Other
Are you in a safe situation currently?
Yes
No
Other
What is your current job?
What is your highest level of education?
Some high school (or less)
High School graduate
GED
In college
Some college
College graduate
In technical school
Some technical school
Technical school graduate
In graduate school (masters degree, medical degree, law degree, etc.)
Some graduate school (masters degree, medical degree, law degree, etc.)
Graduate school (masters degree, medical degree, law degree, etc.)
Other
Arrest History (choose all that apply):
No arrest history
DWI / DUI
Drug possession
Drug possession with intent to distribute
Theft (misdemeanor)
Theft (felony)
Assault (misdemeanor)
Assault (felony)
Driving on a restricted license / without a license
Sexual Assault / Rape
Attempted Murder
Murder
Other
Are you on probation?
yes
no
Other
Should be Empty: