New HC Intake Form with Consent to Treat

New Patient Health Intake

Please take a few minutes to complete the following form. This can be done before the visit or in clinic before your appointment.
In your words, why do you need a visit?
For example, you may say, "I have left knee pain" or "I have anxiety caused by trauma in my past"
Patient Name*

First NameLast Name
Preferred Name
What would you like for us to call you?
Preferred Pronouns
E-mail*
please use the same as your login.evs.gov email if you have one.
Phone Number*
Social Security Number*
9-digits with no dashes in between
Social Security Number*
9-digits with no dashes in between
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Height in inches
Weight in lbs
Race and Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanHawaiian or Pacific IslanderWhiteHispanic or LatinoOther
Birth Sex

FemaleMaleIntersex
Pregnancy

Pregnant or Breastfeeding
Pregnancies
Children
Gender Association

FemaleMaleNon-BinaryGenderqueerTransgender MaleTransgender FemaleOther/Prefer not to answer
Sexual Orientation

StraightHomosexualBisexualAsexual
Medications
Cannabis / Marijuana

CBD (Hemp)THC (Marijuana)
Cannabis / Marijuana forms of use

Edible / tincture oilFlower (bud)VapeConcentratesTopical balms/creams
Allergies, (food, medicine, environment)?

yesno
Allergies, (food, medicine, environment)
Patient Medical History

Alzheimer'sAnemiaArthritis (OA, RA, other)Back painNeck painBlood Disorders (anemia, clotting dsdr.)Brain disorders (epilepsy, trauma, etc.)Bladder (cystitis, neurogenic)Cancer, specify in OtherChronic pain, specify in OtherCirculation (stroke, phelbitis, etc.)DiabetesDystonia (spasms, tremors, Parkinsons)Ear (tinnitus, hearing loss)Eating disorder (anorexia, bulimia)Endocrine (thyroid, adrenal, hormones)Eye (glaucoma, cataracts, macular deg)Genital/GYN problemsHeadache/Migraine headacheHeart diseaseHerpes/Herpes zoster (shingles)High blood pressureHIV/AIDSIntestinal disorders (ulcers, colitis, IBS, reflux)Kidney disease (stones, renal failure)Liver disease (cirrhosis, hepatitis)Lung disease (asthma, emphysema, COPD)Mental health disorders (see below)Multiple sclerosis (neurodegenerative disease)Prostate diseaseRheumatic disease (Lupus, other autoimmune disease)Skin disorders (psoriasis, eczema, pruritis)Sleep disorders (insomnia, sleep apnea, restless legs)Substance abuse (see below)Weight loss or gain

Mental Health History

	Age or date
ADD or ADHD
Anger
Anxiety
Bipolar
Brain trauma
Dementia
Depression
Mood disorder
PTSD
Schizophrenia

Daily Living

	yes	no
Have you often felt down, depressed, or hopeless?
Have you felt very little interest or pleasure in things you used to enjoy?
Do you often feel under extreme stress?
Did you worry that your food would run out before you got money or Food Stamps?
Did the food you bought just not last and you did not have money to get more?
Do you feel like you need to cut back on your alcohol use?
Have you used an illegal drug or prescription medication for nonmedical reasons or not as prescribed?
In the past year, have you spent more than 2 nights in a correctional facility?

Surgeries and approximate dates
Other Mental Health, Medical, or Family History
Caffeine Use

NeverFormerSometimesDaily
Caffeine Type

CoffeeSodaEnergy DrinksTeaPre-workout
Tobacco Use

NeverFormerSometimesDaily
Tobacco Smoking, chew, evape History
Alcohol Use

NeverFormerSometimesDaily
Alcohol History
Illicit Drugs (do not include cannabis)

NeverFormerSometimesDailyI am on probation or paroleI have a pending cannabis case
Illicit Drugs (do not include cannabis) details
what, when, how long
Marital Status

SingleMarriedSeparatedDivorcedWidowedDatingEngagedPartner
Who do you live with

Spouse/Sig OtherAloneFriendsRoommateChildrenFamilyPets
Work Status

StudentRetiredDisabilityUnemployedFull timePart timeTemporaryStay-at-home
Exercise

DailyNo exerciseOnce a week2-3 days a week4+ days a week
Diet

AmericanLow CalorieLow FatLow SaltLow CarbDiabeticVeganVegetarian
How much water do you drink a day?
Highest level of schooling

GED/DiplomaAssociatesBachelorsMastersDoctorateI did not graduate
Armed Forces

MarinesArmyNavyCoast GuardAir ForceMerchant MarinesNational Guard
History of Abuse

NoPhysicalEmotional/PsychologicalSexualEconomic/Financial

History of Abuse Questions

	Yes	No
Do you ever feel unsafe at home, with family or friends?
Do you have people that you can talk to in whom you can trust and confide?
Have you been afraid of your partner?
Do you and your partner fight a lot?
Has a partner threatened, shoved, hit, kicked or hurt you physically in any way?
Are you a refugee?

Parent Questionaire

	yes	no
Do you need the phone number to Poison Control?
Do you need a smoke detector for your home?
Do you often feel your child is difficult to take care of?
Do you sometimes find you need to hit, slap, or spank your child?
Do you wish you had more help with your child?
Do you need help with child care?
Do you feel like your child might need help with eating difficulties?
Do you feel like your child may need help with talking?
Do you feel like your child may need help with reading or other school activities?
Do you feel like your child may need help with fine/gross/ motor skills? (walking, writing, etc.)
Are you aware of any history of abuse that your child may have endured?

Do you need help with any of the following?

DrivingShopping for foodTaking medicationsHouseworkPreparing MealsFinancesBathingEatingDressingUsing the restroomWalking, I use a cane, walker, or wheel chair
Financial Help

FoodRent/MortgageUtilitiesTransportation
Medical Help

CopaysMental health servicesSubstance abuseDental CareMedications
Social Help

ClothingEmploymentIndividual and/or Family supportLiving Will/Advance Directive
Emergency Contact:

First NameLast Name
Relationship

SpouseMotherFatherSiblingChild
Emergency Contact Phone Number
List other health care providers seen on a regular basis, name & specialty
Medical Record Capture – take a photo of the page listing the diagnosis, if you have them now.
Medical Records

Browse Files
If you have medical records, tests, or visit notes from previous treatment, please mention them here. Specifically, if you checked Crohn's, ulcerative colitis, HIV, PTSD, epilepsy, or cancer, ALS, a terminal illness, or have a referral from your medical provider to be evaluated by UTHC; please let us know and we will have you upload it before your appointment. Cancelof
My treatment goals include

ALSAlzheimer'sReduce AnxietyHelp AppetiteAutismCont. TreatmentHelp CreativityHIVColitisCrohn'sImprove FocusGI ImprovementMental HealthMSMuscle SpasmTreat NauseaReduce Pain RxTreat PainTreat PTSDReduce Rx MedsRelaxationSeizuresSleep BetterStay Healthy
Other Treatment Goals.
How did you hear about us?
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New Patient Health Intake