KindlyMD Self Screening Form
See if KindlyMD services are right for you. If you need assistance or have questions, please call or text 385.388.8220. This information is private and not shared.
Name
*
First Name
Last Name
How did you hear about us?
*
Online Search
Billboard
Doctor Referral
Word of Mouth
Social Media
Email
YouTube
Utah State Website
Podcast/Radio
Dispensary
Salt Baked City/Magazine
Event Booth
Flyer
Other
E-mail
*
Phone Number
*
Age
*
Zip Code
*
My main complaint is:
*
Physical Illness or Injury
Mental Health
Chronic Pain
Other
Tell us a little about it:
*
How long has this bothered you?
2 weeks or longer
6 months or longer
1 yr or longer
2 yrs or longer
3 yrs or longer
Less than 2 weeks
Do you take prescription medications?
Yes
No
Do you take opioids, ADHD, or mental health medications?
Yes
No
Rate your mental or physical pain (on average) for the past week:
0 (none)
1
2
3
4
5 (as bad as you can imagine)
During the past week, rate how your condition has interfered with your enjoyment of life:
0 (Does not interfere)
1
2
3
4
5 (Unable to carry on any activities)
In the past week, rate how your condition has interfered with your day-to-day activity:
0 (Does not interfere)
1
2
3
4
5 (Completely interferes)
Would you like to discuss alternative medicine options/getting a Medical Card during your visit?
*
Yes
No
Submit
Tag for AC
Should be Empty: