Teleholistic

New Patient-Intake Form

Complete as much as you can for our providers to be best prepared for your visit. Mark “N/A” or “I don’t know” for sections that are not applicable or unknown to you.

Name

First Name

Last Name

Address

Phone

(###)

###

####

Zip Code

Date of Birth

YYYY

Reason for visit today?

Current Medications and Dosages

Medication History (preferably mental health medications)

Allergies

Emergency Contact-Name, Number, Relation

Current Profession

Medical, Surgical and Social History

Preferred Pharmacy Address

Last Doctor's Appointment Date, Any Restrictions or Worries from that visit?

When was your last visit with a mental health therapist?

When was your last appointment with a psychiatric provider?

Do you currently have a prescription of or use Xanax, Adderall or other stimulants or Benzodiazepines?

Do you have high blood pressure or diabetes?

How many cigarettes do you smoke daily? Per week?

How much Marijuana do you use per day? Per week?

How many cups of alcohol do you drink per day? Per week?

Please list any other important facts about yourself to improve treatment: