New Patient Paperwork

Patient Name*

First NameLast Name

Patient Date of Birth*

MonthDayYear

What type of service are you interested in scheduling?*

Interventional Psychiatry (TMS, Ketamine, and/or Research) with Behavioral Health Medication ManagementIntegrated Care (Combination of at least two of the following: Primary Care, Behavioral Health Medication Management, and Therapy)Interventional Psychiatry (TMS, Ketamine, and/or Research) onlyBehavioral Health Medication Management OnlyPrimary Care OnlyTherapy Only

Patient Gender*

MaleFemale

Phone Number: Primary #*

Please enter a valid phone number.

Is the patient 19 years of age or older?*

YesNo

Do you have a legal guardian or power of attorney?*

YesNo

Legal guardian/Power of Attorney:*

How did you first hear about Alivation Health? *

Were you referred here?*

YesNo

By whom?*

Would you be interested in seeing a Behavioral Health provider at Alivation Health?*

YesNoThis is the reason for today's visit

Have you seen a Psychiatrist, Therapist, or Counselor in the past?*

YesNo

Provider information *

Would you like us to send or receive any information to/from the above provider?*

YesNo

**After you complete this form, please return to the Patient Information page to complete a Release of Information form.

Have you seen a Primary Care Provider before?*

YesNo

The date of my last physical was: (MM/YYYY)blanks*.

Provider information *

Would you like us to send or receive any information to/from your Primary Care Provider?*

YesNo

**After you complete this form, please return to the Patient Information page to complete a Release of Information form.

Would you be interested in using Alivation Pharmacy for your medications?*

YesNo

Would you like to have your other providers' scripts sent to Alivation Pharmacy?*

YesNo

Which Pharmacy would you like to use?

Where were you born? *

Where were you raised?*

Where do you live now?*

Who raised you?*

Do you have any siblings?*

YesNo

Sibling's information*

Are you currently married?*

YesNo

How long?*

Were you previously married?*

YesNo

How long? *

Select one:*

WidowedDivorced

Do you have any children?*

YesNo

Child's name*

Birth weight *

Birth length*

Any complications during this child's pregnancy (bleeding, infection, toxemia) ?*

YesNo

Please explain complications during pregnancy:*

Any complications during this child's labor (breach, prolonged, slow heart rate in baby)?*

YesNo

Please explain complications during labor:*

Any problems during this child's delivery (c-section, forceps, heavy bleeding, premature, late)?*

YesNo

Please explain problems during delivery:*

Any problems during this child's hospital stay(yellow jaundice, trouble with formula, infections)?*

YesNo

Please explain problems during hospital stay:*

Has Child Protective Services (CPS) been involved?*

YesNo

Please explain*

Do you have a Case/Social worker?*

YesNo

What is his/her name?*

First and Last name

How long have you lived at your current address?*

Does anybody else live in your household?*

YesNo

Please list the individual(s) who live with you:*

Are you currently in school?*

YesNo

Which grade?*

What is the highest level of education that you have completed?*

Are you employed?*

YesNo

Name of employer and occupation*

Select one*

RetiredStudentDisabilityOther, specify below

Other specification of employer

Are you currently, or have you previously been, on disability?*

YesNo

Please explain disability:*

Do you have, or have you had, any legal offenses or charges?*

YesNo

Please explain offenses/ charges:*

Do you have a religious or spiritual preference?*

YesNo

Please list religious or spiritual preference here:*

Have you ever had any head/brain trauma, concussion, or hit your head and felt foggy, lightheaded, or dizzy?*

YesNo

Did you ever lose consciousness?*

YesNo

Did you receive treatment for this?*

YesNo

When and where did you receive treatment:*

Have you received a tetanus shot before?*

YesNo

When was the last date it was received?*

Month-Day-Year

Do you have a pacemaker?*

YesNo

Do you have metal in your head?*

YesNo

Please explain metal in your head:*

Do you currently drink caffeinated beverages?*

YesNo

Days per week*

Drinks per day*

Type(s)*

Are you allergic to any medications, foods, or have any environmental allergies?*

YesNo

Please list allergies (medication/food/seasonal/other)*

Do you have a history of drinking alcohol?*

YesNo

Please fill out history of drinking alcohol. Types of alcohol include, but are not limited to: wine, beer, liquor, etc. You do not need to be specific with the brand or sub-class of alcohol.*

Do you currently or have you used illicit drugs?*

YesNo

Please fill out illicit drugs*

Do you currently or have you smoked cigarettes or used any other tobacco products including vaping?*

YesNo

Please list tobacco products below:*

Have you ever been the victim of physical abuse?*

YesNo

Have you ever been the victim of emotional abuse?*

YesNo

Have you ever been the victim of sexual abuse?*

YesNo

Please explain your physical, emotional, and/or sexual abuse if you are comfortable doing so:

Meals*

Regular low-fatRegularOften skipPrimarily fast food

Exercise*

RegularlyOccasionallyRarelyNone

Seat belts*

YesOccasionallyNone

Do you have an advance directive?*

YesNo

Has a copy been provided for our records?*

YesNo

Please upload your advance directive*

Other pertinent information or patient comments

General*

	Current	Past
Anemia
Unexplained fatigue / weakness
Thyroid problems
Diabetes or high blood sugar
Fever or chills
Unusual lymph glands
Cancer
Rashes
Risk factors for AIDS
Sleep difficulties
None of the above

Head*

	Current	Past
Migraine
Frequent, severe or unusual headaches
Change of vision
Wear glasses /contacts
Glaucoma
Hearing difficulty
Nosebleeds
Sinus problems
Hair loss
Dentures/ bridge
Bleeding gums
Persistent hoarseness
Difficulty swallowing
Hay fever
None of the above

Gastrointestinal*

	Current	Past
Indigestion or heartburn
Ulcer(s)
Unexplained abdominal pain
Vomiting or bleeding
Hepatitis or liver problems
Frequent diarrhea
Constipation
Hemorrhoids
Rectal bleeding
Black tarry bowel movements
None of the above

Urinary*

	Current	Past
Bladder or kidney infection
Difficulty starting or controlling urine stream
Burning with Urination
Slow urine flow
Kidney stones
Blood in urine
Veneral disease
Sexual problems
None of the above

Skin*

	Yes	No
Frequent rashes
Changing mole
Skin Tags

Bone/ Joints/Muscles*

	Current	Past
Painful or swollen joints
Persistent back or neck pain
Muscle cramps
Osteoporosis
None of the above

Psychological*

	Current	Past
Suicidal thoughts
Suicide attempt(s)
Anxiety
Depression
Crying spells
Memory problems
Job or family difficulty
Loss of interest in previously enjoyable activities
None of the above

Neurological*

	Current	Past
Seizure or epilepsy
Stroke
Numbness of face, arm or leg
Weakness of face, arm or leg
Difficulty with speech
Fainting or loss of consciousness
None of the above

Lungs*

	Current	Past
Shortness of breath
Asthma or emphysema
Frequent cough
Coughing up blood or phlegm
Tuberculosis
Recurrent pneumonia or bronchitis
Wheezing
None of the above

Heart*

	Current	Past
Heart murmur
Heart failure
Waking up at night due to shortness of breath
High blood pressure
Rheumatic fever
Chest pain, pressure, discomfort
Heart attack
Irregular heartbeat
Swelling in the legs
Calf pain
Racing heart
Blood transfusion
Easy bruising or bleeding
None of the above

Men*

	Current	Past
Prostate problems
Discharge from penis
Lump in testicles
Erectile dysfunction
None of the above

Women *

	Current	Past	Never
Breast lump
Discharge from nipple
Irregular periods
Abnormal vaginal bleeding or spotting
Abnormal pap test

Women fill in the blank*

	Responses
Number of pregnancies
Number of children
Number of living children
Number of adopted children
Last pap date
Age of onset of periods
Days in cycle (from start to start)
Birth control method

Are you currently pregnant?*

YesNo

Who is your provider?*

Would you like us to send or receive any information to your specialist provider?

YesNo

**After you complete this form, please return to the Patient Information page to complete a Release of Information form.

Are you currently breastfeeding?*

YesNo

Have you seen a specialist?*

YesNo

What is/are his/her name(s)?

Would you like us to send or receive any information to your specialist provider(s)?

YesNo

**Please fill out a Release of Information form in order for us to coordinate care.

Do you currently use a glucometer or other medical equipment?*

YesNo

Brand of glucometer

Other medical equipment

Do you feel well?*

YesNo

Other comments

Do you have ANY blood relative(s) with physical, mental health, or substance abuse history? Including but not limited to: alcoholism, arthritis, asthma, bleeds easily, cancer, diabetes, epilepsy, heart disease, high blood pressure, high cholesterol, kidney disease, mental illness, migraine, stroke, thyroid disease.*

YesNo

Please list ALL blood relatives with a physical, mental health, or substance abuse history: *

Do you had ANY previous surgeries, hospitalizations, or other significant in-patient healthcare events?*

YesNo

Please list OR upload a file. Uploading files is preferable for accuracy. Please list ALL previous surgeries, hospitalizations, or other significant in-patient healthcare events:

Attach a provider’s encounter note(s) detailing such events

Do you have any CURRENT or PAST chronic illnesses?*

YesNo

Please list ALL your CURRENT or PAST chronic illnesses: *

Attach an updated problems list from your provider

Do you CURRENTLY take any medication(s)? Include prescribed, over-the-counter, vitamins, drops, and topicals.*

YesNo

Please list ALL your CURRENT medications, dosages, and times taken each day: *

Have you PREVIOUSLY taken any medications? Include prescribed, over-the-counter, vitamins, drops, and topicals.*

YesNo

Please list ALL your PAST medications, dosages, and times taken each day. *

Patient/ Guardian signature*

Date signed*

Date

Type Guardian Name if Applicable

Please Verify that you are Human*

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8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410

New Patient Paperwork

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