Patient Type I am a... (Required)
About You Patient Name (Required)
First
Last
Legal Sex (Required)
Address (Required) Interpreter needed? (Required)
What Brings You In? Reasons for this visit (Required) Other reason for visit (Required)
Do any of these apply to you? (Required)
Pain, Musculoskeletal, and Recovery Are you currently experiencing any of the following? (Required) How severe is your pain today? (Required) 0 = none, 10 = worst
Tell us more about your pain or symptoms
Onset, better/worse, prior treatment, numbness/tingling/instability
Prior epidurals, injections, or surgeries? (Required)
Primary Care / Sick Visit Do you currently have a PCP? (Required)
If yes - switching or seeking a second opinion? Why?
Top 3 concerns you want addressed
Sick visit symptoms (Required) Chronic conditions you are managing (Required) Sick visit details
Days of symptoms, highest temperature, known exposure, what you have taken, and any chronic conditions that may worsen symptoms
Hormone / HRT Symptoms you are experiencing (Required) Currently on HRT, testosterone, or peptides? (Required) Hormone bloodwork in the last 12 months? (Required) Trying to conceive? (Required) History of contraindications (Required)
Medical Weight Loss Currently on a GLP-1? (Required)
Past GLP-1 use? (Required) What have you tried before? (Required) Relevant history (Required)
IV Therapy Had an IV here or elsewhere before? (Required)
History requiring nurse review (Required)
Allergy / SLIT Even if allergy care was not your main reason - do any of these apply? (Required) Seasonal, year-round, or food-related? (Required) Tested before? (Required) History of anaphylaxis or epinephrine use? (Required)
Sleep Health Sleep-related symptoms (Required) Do any of the following apply? (Required) How much is sleep quality affecting your daily life? (Required) Has a partner observed you stop breathing? (Required) Prior sleep study details
Vein Health & Circulation Are you experiencing any of the following leg symptoms? (Required) When do leg symptoms feel worse? (Required) Do any of the following apply? (Required) How much do leg symptoms affect daily life? (Required) Prior vein procedure (Required)
Currently on blood thinners? (Required)
Physical Exam
Specific concerns for this physical
Physical add-ons interested in (Required)
MRI Review
Questions you want answered
Pre-Op / Post-Op Pre-op clearance or post-op follow-up? (Required)
Workers' Comp / Auto (PIP) Injury
Type Claim # / Adjuster name / Adjuster phone
Body parts injured Seen elsewhere for this injury? Facility + provider
Billing details
Carrier, adjuster, claim #, phone, date of injury, attorney info
Medical History Drug allergies and reactions (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)
Any reaction to anesthesia or contrast dye? (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/COVID details
Dates, duration, amount, quit date
Wellness Screeners
PHQ-9 (Depression) Little interest or pleasure in doing things (Required) Feeling down, depressed, or hopeless (Required) Trouble falling or staying asleep, or sleeping too much (Required) Feeling tired or having little energy (Required) Poor appetite or overeating (Required) Feeling bad about yourself - or that you are a failure or have let yourself or your family down (Required) Trouble concentrating on things, such as reading the newspaper or watching television (Required) 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) Thoughts that you would be better off dead, or of hurting yourself in some way (Required)
GAD-7 (Anxiety) Feeling nervous, anxious, or on edge (Required) Not being able to stop or control worrying (Required) Worrying too much about different things (Required) Trouble relaxing (Required) Being so restless that it is hard to sit still (Required) Becoming easily annoyed or irritable (Required) Feeling afraid as if something awful might happen (Required)
Alcohol Use (AUDIT-C) How often do you have a drink containing alcohol? (Required) How many standard drinks containing alcohol do you have on a typical day when drinking? (Required) How often do you have six or more drinks on one occasion? (Required)
Drug Use (DAST-10) Have you used drugs other than those required for medical reasons? (Required) Do you abuse more than one drug at a time? (Required) Are you always able to stop using drugs when you want to? (No = 1 point) (Required) Have you had 'blackouts' or 'flashbacks' as a result of drug use? (Required) Do you ever feel bad or guilty about your drug use? (Required)
Does your spouse (or parents) ever complain about your involvement with drugs? (Required) Have you neglected your family because of your use of drugs? (Required)
Have you engaged in illegal activities in order to obtain drugs? (Required) Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? (Required)
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)
HIPAA Notice of Privacy Practices (Required) Consent to Treat / Financial Responsibility (Required) Communication preferences (Required) Photo / Video Consent
Scheduling Preferences Preferred day(s) (Required) Preferred time of day (Required) In-person or telehealth eligible? (Required) How quickly do you need to be seen? (Required)
Insurance & Pharmacy Relationship to holder (Required)
Secondary insurance that may cover copays/coinsurance/deductibles? (Required) Does spouse/partner have a different plan? (Required) Do you have an HSA or FSA card? (Required)
Preferred Pharmacy - name / phone / full address
Specialty pharmacy?
Quick Identity & Routing Full Name (Required)
Address (if changed) Preferred contact method (Required) Are you returning for the same concern or something new? (Required)
Which provider or service did you last see us for? (Required)
What's Changed Since Your Last Visit Any new injuries, surgeries, hospitalizations, or ER visits? (Required)
New diagnoses from another provider? (Required)
Changes to your medications, supplements, or vitamins? (Required)
Any new drug allergies or reactions? (Required)
Seen any new specialists or started care with a new provider? (Required)
Insurance / Administrative Updates Has your insurance carrier, member ID, or employer changed? (Required) Has your home address or phone number changed? (Required) Has your emergency contact information changed? (Required) Has your pharmacy changed? (Required)
Updated administrative details
Reason for Return What is your #1 goal for this visit? (Required)
Is there anything specific you want to make sure we address at this appointment?
How would you rate your original concern today vs. when you first started care? (Required) 1 = Same/Worse, 10 = Fully resolved
Is there anything we recommended last time that you have not started yet? (Required)
Services You Haven't Tried Yet Joint pain, muscle soreness, or mobility issues not yet addressed (Required) Medical weight loss or GLP-1 options (Required) Hormonal symptoms - fatigue, low libido, mood changes, menopause (Required) IV therapy or wellness infusions (Required) Sleep concerns - trouble falling/staying asleep, feeling unrested (Required) Allergy symptoms - seasonal, year-round, or food-related / SLIT (Required) Athletic recovery / ARC (compression, NormaTec, muscle recovery) (Required) Leg heaviness, swelling, varicose veins, or circulation concerns (Required) Preventive care, lab work, or a comprehensive physical (Required) Aesthetic or wellness services (Medical Botox, etc.) (Required) Cryotherapy, Infrared Sauna, Red Light Therapy, or Salt Room (Required) Personal training or group fitness classes (Required)
Lifestyle & Performance Snapshot
Current goals (Required) Sleep quality (Required)
Energy levels / fatigue (Required) Stress / mental wellness (Required)
Wellness Check How would you rate your overall health since your last visit with us? (Required) Is there anything you feel has been overlooked, or that you have not had a chance to discuss with your provider?
Logistics & Consent If you had a gap in care, what was the primary reason? (Required) Day preference (Required) Time preference (Required) HIPAA Authorization / Notice of Privacy Practices (Required) Financial Policy & Assignment of Benefits (Required) Consent for Treatment (Required)
Confirm Your Info Full Name (Required)
Preferred contact method (Required) Has anything changed since your last visit? Insurance carrier, member ID, or employer (Required) Has anything changed since your last visit? Home address or phone number (Required)
Has anything changed since your last visit? Emergency contact (Required) Has anything changed since your last visit? Pharmacy (Required)
If anything changed, note it here
Today's Appointment Primary reason for today's visit (Required)
Current Pain & Symptoms Are you currently experiencing any pain or discomfort? (Required) How severe is your pain today? (Required) 0 = no pain, 10 = worst imaginable
How does this compare to when you first started care with us? (Required) 1 = Same or worse, 10 = Fully resolved
Do any of the following apply to you right now? (Required) Tell us more about your pain or symptoms
What makes it better or worse? Any numbness, tingling, weakness, or instability?
Quick Health Update Any new injuries, surgeries, hospitalizations, or ER visits since your last visit? (Required)
New diagnoses from another provider? (Required)
Changes to your medications, supplements, or vitamins? (Required)
Any new drug allergies or reactions? (Required)
Anything your provider recommended last visit that you have not started yet? (Required)
Other Services You'd Like to Explore Joint pain, soreness, or mobility issues not yet addressed (Required) Medical weight loss / GLP-1 options (Required) Hormonal symptoms - fatigue, low libido, mood, menopause, ED (Required) IV therapy or wellness infusions (Required) Sleep concerns - trouble falling/staying asleep, feeling unrested (Required) Allergy symptoms - seasonal, year-round, or food-related / SLIT (Required) Athletic recovery / ARC (compression, NormaTec, muscle recovery) (Required) Leg heaviness, swelling, varicose veins, or circulation concerns (Required) Preventive care, lab work, or a comprehensive physical (Required) Aesthetic or wellness services (Medical Botox, etc.) (Required) Cryotherapy, Infrared Sauna, Red Light Therapy, or Salt Room (Required) Personal training or group fitness classes. (Required)
Quick Wellness Snapshot Sleep quality (Required) Energy levels / fatigue (Required) Stress / mental wellness (Required) Weight / body composition (Required) Is there anything you feel has been overlooked, or have not had a chance to bring up with your provider?
Scheduling & Consent Preferred appointment days (Required) Preferred time of day (Required) How quickly do you need to be seen? (Required) If you had a gap in care, what was the main reason? HIPAA Authorization / Notice of Privacy Practices (Required) Financial Policy & Assignment of Benefits (Required) Consent for Treatment (Required)
HSA/FSA Many patients can use HSA or FSA funds toward copays, deductibles, equipment and more. Let us know if you have one so we can help you make the most of your benefits.
Has your HSA or FSA status changed? Let us know so we can help you make the most of your benefits.
Welcome back! If you have an HSA or FSA, let us know so we can help you make the most of your benefits.
Eligibility depends on your specific plan. Please confirm coverage with your HSA/FSA plan administrator.
Employment Info Any imaging done? (Required) Select all that apply. Select None only if you have not had imaging.
Final Consent & Signature Appointment Reminders (Required) Marketing Communications (Required) Administrative alerts, new services, modalities, locations, and updates on the practice
I have read and agree to the Consent to Treat form (Required)
Time to Update Your HRT / Testosterone Consent (Required)
Welcome back! Our records show you've previously signed a consent form for Hormone Replacement Therapy (HRT) and/or testosterone therapy.
To keep your chart current, we ask patients on or interested in hormone therapy to review and re-sign this consent form periodically. This makes sure you have the most up-to-date information on the benefits, risks, side effects, and monitoring involved, including any changes to our program since you last signed.
Your updated form will be added to your chart so your provider has it on file for your visit. If anything about your health has changed, such as new medications, diagnoses, or surgeries, please let us know so your provider can review it with you.
Questions? Call us at 973-377-6700 .
Review & Re-Sign TRT Consent Form
Review & Re-Sign HRT Consent Form
One More Step: HRT / Testosterone Consent (Required)
Thanks for letting us know you're interested in Hormone Replacement Therapy (HRT) and/or testosterone therapy.
Before your visit, we ask all patients interested in hormone therapy to review and sign our HRT/Testosterone Consent Form. This form explains how hormone therapy works, what's involved in evaluation and monitoring (including lab work), and the potential benefits, risks, and side effects, so you can make an informed decision with your provider.
Your signed form is added to your chart so your provider has it ready at your appointment. Signing does not commit you to starting treatment. Your provider will review your health history and labs with you and answer any questions before any therapy is recommended.
If you have questions before signing, please call us at 973-377-6700 .
Review & Sign TRT Consent Form
Review & Sign HRT Consent Form
I have read and acknowledge the HIPAA Authorization / Notice of Privacy Practices. (Required) I have read and acknowledge the Consent to Treat form (Required) I have read and agree to the TRT Consent Form and HRT Informed Consent Form. (Required)
I have read and agree to the TRT Consent Form and HRT Informed Consent Form (Required)
Remember my contact information on this device for future forms. By checking this box I agree with the statement below (Required) Patient Signature (Required)
Athletic Recovery Appointment Who Is This Session For? (Required) Are You Currently Injured or in Pain? What's Your Recovery Focus? (Required) Any Imaging Done? Select all that apply. Select None only if you have not had imaging.
(Required) I understand this is a request form. A team member will reach out to confirm my appointment, and I agree to receive SMS and email communication related to it.
