New Patient Intake Form

Thank you for completing this HIPAA compliant, confidential medical and mental health history form. Contact Kara at (737) 204-5610 if you have any questions or require assistance.

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* 1. Please provide us with some general information.

First name and first initial of last name (example: Donald G)

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Is it ok for us to leave you a message at the number listed above?

YES

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* 3. Employer

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* 4. Occupation

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* 5. Who referred you?

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* 6. Reason for your visit?

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* 7. Do you have a primary care physician? (If so, who?)

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* 8. What was the date of your last complete physical examination and what were the results?

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* 9. Please list all medication allergies you have and describe your reaction.

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* 10. Please list all of your current and recent medications. Make sure to include doses, how often you take them, how long you have been taking them, and the reason for use.

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* 11. Please list any significant past medications you have taken, including dates and doses if you can recall.

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* 12. Please detail any alcohol and drug use, including social use. Include amounts and frequency of use.

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* 13. Please detail tobacco and caffeine use, including amounts and frequency of use.

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* 14. Please list all of your previous significant medical illnesses, surgeries and hospitalizations. Include locations and dates.

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* 15. Have you every seen a psychiatrist before? If so, list who, when and why.

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* 16. Have you ever seen a therapist or counselor before? If so, please list who, when and why.

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* 17. Have you ever been hospitalized for mental health reasons? If so, please detail when, where and why.

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* 18. Have you ever tried to harm yourself or anyone else? If so, please detail when and any important circumstances.

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* 19. Do you have a family history of any mental health, drug or alcohol issues? Provide details if possible.

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* 20. What medical illnesses run in your family?

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* 21. Describe any significant legal problems you may have, including history of Child Protective Services or Adult Protectice Services interactions.

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* 22. Tell us about any interests, strengths or talents you have.

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* 23. Please use this space to tell us about anything else you believe may be important about you, your past or your situation.

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* 24. Thank you for completing the intake. Please acknowledge, below:

I have reviewed the Austin Clinical Trial Partners Practice Policies, understand and agree to these terms.

I have reviewed the HIPAA (Privacy) Statement and agree to these privacy terms.

I understand that this completing this intake is not a guarantee to care.

Please type your full name to acknowledge