New Patient Paperwork

Patient Name *

First Name Last Name

Date of Birth *

Month Day Year

Gender *

Male Female

Is the patient 19 years of age or older? *

Yes No

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

Yes No

Legal guardian/Power of Attorney: *

How did you first hear about Alivation Health? *

Were you referred here? *

Yes No

By whom? *

Would you like us to send or receive any information to/from the referral source? *

Yes No

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

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

Yes No This is the reason for today's visit

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

Yes No

Provider information *

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

Yes No

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

Would you be interested in seeing a Primary Care Provider (PCP) at Alivation? *

Yes No This is the reason for today's visit

Have you seen a Primary Care Provider before? *

Yes No

Provider information *

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

Yes No

**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? *

Yes No

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

Yes No

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? *

Yes No

Sibling's information *

Sibling's name

Gender

Date of birth

Information

Sibling's information *

Are you currently married? *

Yes No

How long? *

Were you previously married? *

Yes No

How long? *

Select one: *

Widowed Divorced

Do you have any children? *

Yes No

Child's name *

Child's name

Gender

Date of birth

Information

Child's name *

Has Child Protective Services (CPS) been involved? *

Yes No

Please explain *

Do you have a Case/Social worker? *

Yes No

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? *

Yes No

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

Name of person

Relationship to patient

Information

Are you currently in school? *

Yes No

Which grade? *

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

Are you employed? *

Yes No

Name of employer and occupation *

Select one *

Retired Student Disability Other, specify below

Other specification of employer

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

Yes No

Please explain disability: *

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

Yes No

Please explain offenses/ charges: *

Do you have a religious or spiritual preference? *

Yes No

Please list religious or spiritual preference here: *

Birth weight *

Birth length *

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

Yes No

Please explain complications during pregnancy: *

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

Yes No

Please explain complications during labor: *

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

Yes No

Please explain problems during delivery: *

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

Yes No

Please explain problems during hospital stay: *

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

Yes No

Did you ever lose consciousness? *

Yes No

Did you receive treatment for this? *

Yes No

When and where did you receive treatment: *

Have you received a tetanus shot before? *

Yes No

When was the last date it was received? *

Month-Day-Year

Do you have a pacemaker? *

Yes No

Do you have metal in your head? *

Yes No

Please explain metal in your head: *

Do you currently drink caffeinated beverages?

Yes No

Days per week *

Drinks per day *

Type(s) *

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

Yes No

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

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

Item

Reaction(s)

Allergic (medication / food / seasonal / other)

Do you have a history of drinking alcohol? *

Yes No

Please fill out history of drinking alcohol *

Type of Alcohol

How Much

How Often

Date of First Use

Last Use/ Current

Item #1

Item #2

Item #3

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? *

Yes No

Please fill out illicit drugs: *

Type of Drug

How Much

How Often

Date of First Use

Last Use/ Current

Item #1

Item #2

Item #3

Please fill out illicit drugs *

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

Yes No

Please List Tobacco Products Below: *

Type of Product

How Much

How Often

Date of First Use

Last Use/ Current

Brand Name

Item #1

Item #2

Item #3

Please list tobacco products below: *

Have you ever been the victim of physical abuse? *

Yes No

Have you ever been the victim of emotional abuse? *

Yes No

Have you ever been the victim of sexual abuse? *

Yes No

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

Meals *

Regular low-fat Regular Often skip Primarily fast food

Exercise *

Regularly Occasionally Rarely None

Seat belts *

Yes Occasionally None

Do you have an advance directive? *

Yes No

Has a copy been provided for our records? *

Yes No

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

General *

Yes

No

Anemia

Recent weight change

Thyroid problems

Diabetes or high blood sugar

Frequent f ever or chills

Frequent large lymph glands

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

Head *

Yes

No

Frequent headaches

Visual problems (Include glasses)

Glaucoma

Frequent dizziness

Fainting

Epilepsy or seizures

Weakness in arm or leg

Numbness

Frequent ear infections

Hearing difficulty

Ringing in ears

Frequent nosebleeds

Frequent nasal congestion

Difficulty swallowing

Persistent hoarseness

Heart *

Yes

No

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

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

Gastrointestinal *

Yes

No

Indigestion or heartburn

Ulcer(s)

Frequent a bdominal pain

Vomiting bleeding

Hepatitis or liver problems

Frequent diarrhea

Frequent c onstipation

Rectal problems or bleeding

Black tarry bowel movements

Recent change in bowel moments

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

Urinary *

Yes

No

Bladder or kidney infection

Kidney stones

Burning with urination

Difficulty passing urine

Diffculty controlling urine

Getting up all night to urinate

Blood in urine

Bedwetting

None of the above

Skin *

Yes

No

Frequent rashes

Changing mole

Genitalia *

Yes

No

Undescended testes

Behavior *

Yes

No

School problems

Sleep difficulty

Nightmares/terrors

Unusual fears

Problems playing with other children

Poor appetite

Temper tantrums

Development *

Age this Child

Sat up alone

Crawled

Walked

Talked in phrases

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

Breast lump

Discharge from nipple

Irregular periods

Abnormal vaginal bleeding or spotting

Abnormal pap test

None of the above

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? *

Yes No

Who is your provider? *

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

Yes No

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

Are you currently breastfeeding? *

Yes No

Have you seen a specialist?

Yes No

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

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

Yes No

**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? *

Yes No

Brand of glucometer *

Other medical equipment *

Do you feel well? *

Yes No

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.

Yes No

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?

Yes No

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?

Yes No

Please list OR upload a file. Uploading files is preferable for accuracy. 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.

Yes No

Would you like to list, attach or include both of your CURRENT medications? *

List Attach Both

Please list OR upload a file. Uploading files is preferable for accuracy. Please list ALL your CURRENT medications, dosages, and times taken each day:

Upload an updated current medication list from your provider(s) or Pharmacy

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

Yes No

Would you like to list, attach or include both of your PAST medications? *

List Attach Both

Please list OR upload a file. Uploading files is preferable for accuracy. Please list ALL your PAST medications, dosages, and times taken each day.

Upload an updated previous medication list from your provider(s) or Pharmacy

Upload insurance card

Upload driver license

Patient/ Guardian signature *

Clear

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

Please select the option that best describes you

Please mark all the symptoms that apply: