KindlyMD Self Screen

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 NameLast Name
How did you hear about us?*

Online SearchBillboardDoctor ReferralWord of MouthSocial MediaEmailYouTubeUtah State WebsitePodcast/RadioDispensarySalt Baked City/MagazineEvent BoothFlyerOther
E-mail*
Phone Number*
Age*
Zip Code*
My main complaint is:*

Physical Illness or InjuryMental HealthChronic PainOther
Tell us a little about it:*
How long has this bothered you?

2 weeks or longer6 months or longer1 yr or longer2 yrs or longer3 yrs or longerLess than 2 weeks
Do you take prescription medications?

YesNo
Do you take opioids, ADHD, or mental health medications?

YesNo
Rate your mental or physical pain (on average) for the past week:

0 (none)12345 (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)12345 (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)12345 (Completely interferes)
Would you like to discuss alternative medicine options/getting a Medical Card during your visit?*

YesNo
Tag for AC
Should be Empty:

KindlyMD Self Screening Form