Who Are You? I am a...(Required) Patient Name(Required)
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Legal Sex(Required) Address(Required)
Interpreter needed?(Required)
Returning Patient: Update Block Since we last saw you, have you had any new diagnoses, surgeries, hospitalizations, ER visits, or seen any new specialists?(Required) Why we ask: If you're a returning patient, your health may have changed since your last visit. New diagnoses, surgeries, hospital or ER visits, or new specialists all affect how we treat you safely and which records we need to request. Even small updates help us avoid duplicate testing and keep your care coordinated.
Please briefly describe.(Required)
Have you had any change to your insurance, employer, pharmacy, or home address?(Required) Why we ask: Insurance, employer, pharmacy, and address changes are the #1 cause of claim denials and prescription delays. Confirming these up front means we can verify your benefits before your visit and send prescriptions to the right pharmacy so you're not surprised by a bill or a script that didn't go through.
What changed?(Required) Updated Home Address(Required)
Do you (or your spouse/partner) have a secondary insurance that may help cover copays, coinsurance, or deductibles?(Required) Why we ask: A second insurance plan can pick up costs your primary plan leaves to you - copays, coinsurance, or your deductible. Telling us now means we can bill both plans correctly and you pay less out of pocket.
Does your spouse or partner have a different insurance plan than yours?(Required) Why we ask: If your spouse or partner carries a separate plan, you may be eligible for coordinated coverage that lowers your share of the cost. This is a quick check that can save you money, even if the answer is no.
Do you have an HSA or FSA card?(Required) Why we ask: Many of our services qualify for tax-free HSA/FSA dollars. Knowing you have one lets our front desk apply it correctly at checkout so you get the savings you're entitled to.
Has anything changed since your last visit? Check all that apply.(Required) If nothing changed, select 'Nothing has changed - everything on file is current.' Active patients should not re-upload ID, insurance cards, or pharmacy documents here.
Updated Home Address
Please briefly describe the new health changes.(Required)
What Brings You In? Primary Reasons(Required) Select all primary reasons for this appointment.
Secondary reasons(Required) Select any additional concerns, or choose None.
Do any of these apply to you? (Check all that apply)(Required)
Pain / Musculoskeletal / Recovery Details Are you currently experiencing ANY of the following? (Check all that apply)(Required) This field is hidden when viewing the form
What makes it better?
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What makes it worse?
Tell us more about your pain or symptoms - When did it start?
- What makes it better or worse?
- Have you tried treatment already?
- Any numbness, tingling, weakness, or instability?
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Numbness, tingling, weakness, instability? This field is hidden when viewing the form
Describe numbness, tingling, weakness, or instability
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Have you tried treatment already? This field is hidden when viewing the form
Treatment details and dates
Any imaging done?(Required) Prior epidurals, injections, or surgeries?(Required) Prior epidurals, injections, or surgeries details(Required)
Primary Care / Sick Visit Details Do you currently have a PCP?(Required) If yes, are you looking to switch or seeking a second opinion? Why?
Top 3 concerns you want addressed
Chronic conditions you are managing(Required) Sick visit symptoms(Required) Known exposure(Required) Have you taken anything for it already?
Chronic conditions that make this worse(Required)
HRT / Hormone Details Symptoms you are experiencing(Required) Currently on HRT, testosterone, or peptides?(Required) If yes, what specifically, dose, prescriber, how long, last labs?(Required)
Hormone bloodwork in the last 12 months?(Required) Trying to conceive?(Required) History of contraindications(Required)
Medical Weight Loss Details Currently on a GLP-1?(Required) Current GLP-1 details(Required)
Past GLP-1 use?(Required) Past GLP-1 details(Required)
Relevant history(Required) What have you tried before?(Required)
IV Therapy Details Had an IV here or elsewhere before?(Required) History requiring nurse review(Required)
Allergy / SLIT Details Symptoms(Required) Are symptoms seasonal, year-round, or food-related?(Required) Tested before?(Required) Currently on antihistamines, steroids, or biologics?
History of anaphylaxis or epinephrine use?(Required)
Sleep Health Screening Are you experiencing any of the following sleep-related symptoms? (Check all that apply)(Required) Do any of the following apply to you? (Check all that apply)(Required) How much is your sleep quality affecting your daily life? (Select one)(Required) This field is hidden when viewing the form
Sleep health screener
Has a partner observed you stop breathing?(Required) Prior sleep study details
Currently using CPAP / BiPAP / oral appliance?
Vein Health & Circulation Screening Are you experiencing ANY of the following leg symptoms? (Check all that apply)(Required) When do your leg symptoms feel worse?(Required) Do any of the following apply to you? (Check all that apply)(Required) How much do your leg symptoms affect your daily life?(Required) This field is hidden when viewing the form
Vein health screener
Prior vein procedure(Required) Currently on blood thinners?(Required)
Annual / Executive / Athlete / Cardiopulmonary Physical Details Specific concerns for this physical
Physical add-ons interested in(Required)
MRI Review Details Upload images / disc info if available
Questions you want answered
Pre-Op / Post-Op Details Pre-op clearance or post-op follow-up?(Required) Type Body parts injured Seen elsewhere for this injury? Facility + provider
Attorney info if applicable
Medical History - New Patients Drug allergies and reactions(Required)
Any reaction to anesthesia or contrast dye?(Required) Describe anesthesia or contrast reaction(Required)
Current Rx, OTC, supplements, vitamins, peptides, HRT, GLP-1s(Required)
Past medications / therapies stopped in last 5 years and why(Required)
Past surgeries and hospitalizations(Required)
Past / current conditions(Required) Female patients only - pregnancy, nursing, LMP, menopause, birth control
Smoking, Vaping & Exposure History Current smoking history?(Required) Former smoking history?(Required) Vaping history?(Required) Secondhand smoke exposure?(Required) Family history of emphysema?(Required) Family history of lung cancer?(Required) 9/11 or occupational dust/smoke exposure?(Required) COVID history?(Required) Additional smoking, vaping, exposure, or COVID history details
Use this space for dates, duration, amount, quit date, exposure details, or anything else you want the care team to know.
1. Little interest or pleasure in doing things(Required) 2. Feeling down, depressed, or hopeless(Required) 3. Trouble falling or staying asleep, or sleeping too much(Required) 4. Feeling tired or having little energy(Required) 5. Poor appetite or overeating(Required) 6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down(Required) 7. Trouble concentrating on things, such as reading the newspaper or watching television(Required) 8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual(Required) 9. Thoughts that you would be better off dead, or of hurting yourself in some way(Required) 1. Feeling nervous, anxious, or on edge(Required) 2. Not being able to stop or control worrying(Required) 3. Worrying too much about different things(Required) 4. Trouble relaxing(Required) 5. Being so restless that it is hard to sit still(Required) 6. Becoming easily annoyed or irritable(Required) 7. Feeling afraid as if something awful might happen(Required) 1. How often do you have a drink containing alcohol?(Required) 2. How many standard drinks containing alcohol do you have on a typical day when drinking?(Required) 3. How often do you have six or more drinks on one occasion?(Required) 1. Have you used drugs other than those required for medical reasons?(Required) 2. Do you abuse more than one drug at a time?(Required) 3. Are you always able to stop using drugs when you want to? (No = 1 point)(Required) 4. Have you had 'blackouts' or 'flashbacks' as a result of drug use?(Required) 5. Do you ever feel bad or guilty about your drug use?(Required) 6. Does your spouse (or parents) ever complain about your involvement with drugs?(Required) 7. Have you neglected your family because of your use of drugs?(Required) 8. Have you engaged in illegal activities in order to obtain drugs?(Required) 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?(Required) 10. Have you had medical problems as a result of your drug use (memory loss, hepatitis, convulsions, bleeding)?(Required)
Emergency Contact + Consent Emergency Contact Name(Required)
First
Last
HIPAA Notice of Privacy Practices(Required) I have read and acknowledge the HIPAA Notice of Privacy Practices.
Consent to Treat / Financial Responsibility(Required) I understand and agree to consent to treat and financial responsibility.
Communication preferences(Required) Photo / Video Consent I consent to photo/video use where applicable.
Preferred day(s)(Required) Preferred time of day(Required) In-person or telehealth eligible?(Required) Only visible for approved telehealth-capable visit types.
How quickly do you need to be seen?(Required)
Insurance + Pharmacy Relationship to holder(Required) Do you or your spouse have a secondary insurance that may cover copays, coinsurance, or deductibles?(Required) Does your spouse or partner have a different insurance plan than yours?(Required) Would you like to add it as your secondary?(Required) Do you have an HSA or FSA card?(Required) HSA / FSA Card Type(Required) Pharmacy Full Address
Specialty pharmacy? Different specialty pharmacy for specific meds?
I have viewed and agree to the consent form above(Required) 
