Village Family Clinic & Wellness Center

Available Forms

#1 NEW PATIENT - Mood disorder #2 NEW PATIENT- ADHD assessment #3 NEW PATIENT Health History form #4 NEW PATIENT - PHQ-9 #5 NEW PATIENT Epworth Sleepiness Scale #5 NEW PATIENT Epworth Sleepiness Scale #6 NEW PATIENT CUXOS Anxiety Scale *Binge eating disorder assessment *FOLLOW-UP FORM: Anxiety *FOLLOW-UP FORM: Depression MDQ follow-up Medication renewal form *FOLLOW-UP FORM: ADHD Patient survey

#3 NEW PATIENT Health History form

We are only seeing new patients ages 18 and over

Insurance information

We accept Regence, Premera, and most BCBS plans and United. It is your responsibility to determine your insurance benefits and network status. We offer a time-of-service discount for patients with out-of-network insurance plans - please contact us for more information.

Health History

This health history form is for new patients for their initial visit. This information is securely imported into your chart.

Name *

Date of Birth *

MM/DD/YYYY

E-mail address *

Phone number *

What pharmacy will you be using? Please include name and location. *

What are the problems for which you are seeking help? *

What have you done to cope with these issues in the past? *

What are your goals for treatment? *

Past Medical History *

check all that apply

Explanation of Illnesses

(Please include any illnesses that were not include in list above)

Serious injury (especially concussion)

please describe any serious injuries

Current medications/ *

Please list any medications or supplements you are taking with dose and frequency.

Past medications *

Please specify dates you took the medication and the dosage

Allergies *

Please list any allergies (penicillin, trees, nuts, etc)

What time do you usually go to bed? *

Do you drink alcohol? *

How much per week?

Do you smoke? *

How many cigarettes per day?

Do you consume caffeine? *

How many cups per week?

Do you use recreational drugs? *

What kind/how frequently?

Do you have a special diet? *

Explain special diet

How often do you exercise? *

Do you have any children? If so, how many?

Family History of Illness *

check all that apply

Which family members have the conditions?

Have you ever been hospitalized for reasons related to mental health? *

Yes

If so, please list year and location of hospitalization

What is the most stressful thing in your life right now? *

Do you suffer from any of the following? *

OK to select more than 1

Are you currently... *

Employed

Student

At home/homemaker

Unemployed

Disabled

Retired

OK to select more than 1

What do you do for work? How satisfied are you with your current work situation? (if applicable)

In the last year, have there been any major changes in your life like marriage, divorce, death of a family member or close friend, illness or injury, or change in job situation? *

Are you currently married or living with a significant other? *

Yes

Who lives in your home? *

Can you count on anyone to provide you with emotional support such as talking over problems or helping you make a difficult decision? If so, who? *

What do you like to do for fun? How do you relax? *

How did you hear about our office? *

May we charge balance due to your card on file after insurance has processed the claim? *

Yes

Would you like us to keep a credit card on file for you? *

Yes

Emergency Contact

Name of emergency contact *

Relationship *

Phone number *

IMPORTANT INSURANCE INFORMATION BELOW

By clicking this box, I understand that Village Family Clinic accepts Premera, Regence, BCBS and United Healthcare insurance plans. I understand that if I have an out-of-network insurance plan, (such as Aetna or Cigna) I am responsible for the cost of my appointment. I also understand that if I have a Premera Individual plan, I may need pre-authorization before the appointment from my primary care provider. *

* Required field

Village Family Clinic & Wellness Center

Available Forms

#3 NEW PATIENT Health History form

***We are only seeing new patients ages 18 and over***

Insurance information

Health History

Emergency Contact

IMPORTANT INSURANCE INFORMATION BELOW

We are only seeing new patients ages 18 and over