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Patient Portal
About
Register
Resources
Resources
Hiring
Blog
Make a Payment
Contact Us
Click Here to access your Patient Portal
Please Complete the New Patient Intake Questionnaire Below
New patient intake questionnaire
Patient Portal Form
Name
*
First Name
Last Name
What is your major complaint and current symptoms
*
Have you previously suffered from this complaint?
*
Yes
No
If Yes, enter previous Provider seen for complaint, describe treatment
Aggravating Factors
*
Relieving Factors
*
Current Symptoms
*
Anxiety
Appetite Issues
Avoidance
Crying Spells
Depression
Excessive Energy
Fatigue
Guilt
Hallucinations
Impulsivity
Irritability
Libido Changes
Loss of Interest
Panic Attacks
Racing Thoughts
Risky Activity
Sleep Changes
Suspiciousness
If not listed above, what are your current symptoms
Exercise Frequency
*
Allergies
*
Current Medications
*
Previous Medications
Previous Diagnoses/Mental Health Treatment
Dates Treated
Previous Medical Conditions
Previous surgeries
Were you adopted, if yes, at what age?
How is your relationship with your mother?
How is your relationship with your father?
How many siblings do you and what are there ages? (If applicable)
Are your parents married?
Yes
No
N/A
Did your parents divorce? If yes, how old were you?
Did your parents remarry? If yes, how old were you?
Who raised you? Where did you grow up?
Relevant Family Medical History
Relevant Family Mental Health History, and were they treated with medications? If so, which medications?
*
Work Status:
*
Full-time
Part-time
Unemployed
Disabled
Student
Other
Are you married? If yes, for how long?
*
Are you divorced? If yes, how long have you been divorced?
What is your sexual orientation?
Are you sexually active
Yes
No
How is your relationship with your partner (if applicable) ?
Do you have child(ren)? If yes, how is your relationship with your child(ren)?
Are you a member of a religious/spiritual group?
Have you ever been arrested? If yes, when and why?
Have you ever tried the following?
*
Alcohol
Tobacco
Marijuana
Cocaine
Stimulants (Pills)
Ecstasy
Methadone
Tranquilizers
Pain Killers (Opioids)
None of the above
Notable frequency and use related to the above checklist
Have you ever been treated for drug/alcohol abuse? If yes, when?
Do you smoke cigarettes? If yes, how many per day?
Do you drink caffeinated beverages? If yes, how many per day?
Have you ever abused prescription drugs? If yes, which ones?
Is there anything else you want the clinical to know?
Thank you!
