New Patient Information

New Patient Information
Name*

First Name Last Name
Birth Date

Month Day Year
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How did you hear about our practice?*
If other, please list below
Payment Information
Primary Insurance Company*
Primary Insurance Member ID Number
Secondary Insurance Company*
Secondary Insurance Member ID Number
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?*

YesNo
Did you desire to stop using, but were unable to do so?*

YesNo
Did you spend a significant amount of time obtaining opioid drugs?*

YesNo
Did you have cravings or desires to use opioid drugs?*

YesNo
Did your use of these drugs make it so that you were unable to fulfill your obligations?*

YesNo
Did your use of these drugs cause you personal, professional or legal problems?*

YesNo
Did you give up activities due to your use of opioid drugs?*

YesNo
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)?*

YesNo
Did you continue to use opioid drugs despite the problems that your use may have caused?*

YesNo
Did you develop a tolerance to opioid drugs (a need for greater amounts of drugs to achieve the desired effect)?*

YesNo
Did you have withdrawal symptoms if you did not use drugs on a routine basis?*

YesNo
History
Why do you want to be seen?*

Treatment of pain pill / heroin addictionTreatment of alcohol addictionTreatment of cocaine / methamphetamine addictionTreatment of tobacco addictionTreatment of other addiction(s)Treatment of mental health problemsOther
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 / NaltrexoneMethadoneSuboxoneInpatient TreatmentsIntensive Outpatient TreatmentsCounselingOther
On what date did you last use opiates / heroin / Suboxone?

MonthDay Year
Date
How many years has this been a problem for you?
Why did you begin using? (Please pick all that apply.)

Recreational usePrescribed by a physicianSelf treatment of depression / anxiety or other problemsOther
Longest period of time not using drugs / alcohol?
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.)

GamblingInternetShoppingSexGamingOther
Do you have any of the following illnesses? (Please pick all that apply.)

Opiate Use DisorderAlcohol Use DisorderStimulant Use Disorder (cocaine / methamphetamine)Sedative Use Disorder (benzodiazepine)Tobacco Use DisorderAnxietyDepressionBipolar DiseasePost Traumatic Stress DisorderObesityDiabetesThyroid DiseaseHigh Blood PressureHigh CholesterolHeart DiseaseStrokeCancerHeartburnConstipationNauseaAsthmaCOPD / EmphysemaUrinary problemsGynecologic problemsBackpain / back problemsMuscle problemsSleep problemsNo medical problemsOther
Have you had any surgeries? (Please pick all that apply.)

Ear surgery (including tubes as a child)Eye surgery (cataracts, etc.)TonsillectomyThyroid surgeryThroat surgeryLung surgeryHeart surgeryBowel surgeryHysterectomy (removal of uterus)Oophorectomy (removal of ovary / ovaries)Orthopedic surgery (bone or joint surgery)D&CTubal LigationVasectomyOther
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.)

ChickenpoxMeaslesPneumoniaMumpsRubellaOther
Are you up to date on your vaccinations?

YesNoUnknown
Who is your primary care physician?*
How do we contact your primary care physician?
When did you have your last annual exam?
Family Medical History
Did your father have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Did your mother have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Did your brothers or sisters have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Did your maternal (mother) grandparents have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Did your paternal (father) grandparents have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Did your children have any of the following illnesses? (Please pick all that apply.)

Alcohol Use DisorderDrug Use Disorder (any drugs - legal or illegal)DiabetesHeart DiseaseStrokeAsthmaBlood clotting problemsCancerDepressionAnxietyBipolar DiseaseUnknownOther
Social History
What is your marital status?
Where do you live?
How many people live with you?
Do any of these people use drugs / alcohol?

YesNoOther
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?

YesNoOther
What is your current job?
What is your highest level of education?

Some high school (or less)High School graduateGEDIn collegeSome collegeCollege graduateIn technical schoolSome technical schoolTechnical school graduateIn 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 historyDWI / DUIDrug possessionDrug possession with intent to distributeTheft (misdemeanor)Theft (felony)Assault (misdemeanor)Assault (felony)Driving on a restricted license / without a licenseSexual Assault / RapeAttempted MurderMurderOther
Are you on probation?

yesnoOther
Should be Empty:

New Patient Information

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Addiction Symptoms

History

Family Medical History

Social History