Wyoming Wellness Center

Medical & Psychological Intake Form

Please fill out this form completely. Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name * Last Name * Date of Birth * Sex * Cell Phone * Email Address *

Additional Information

Preferred Language Emergency Contact Name * Emergency Contact Number * Who is your Primary Care Provider (PCP)? * What is the Telephone number of your PCP? *

Medical History

What is your Height? * What is your Weight? * List ALL medications you are currently taking (INCLUDING OVER THE COUNTER, VITAMINS, & SUPPLEMENTS)) * List ALL Medication ALLERGIES * List ALL Environmental/Food ALLERGIES * Medical Conditions: Please check all Medical conditions you are being treated for or have been diagnosed with * Details of Any Marked Conditions, or "Something Else" Marked above or Mark NA * Specific Medical Conditions: Check ALL Conditions you have now or in the past. * List & Describe ANY Medical Conditions you Marked Above or Mark NA *

Surgical History

Please check all Surgical Procedures you have had: * Describe (specific name and details) of ANY other MAJOR Surgical procedures Selected Above / or Not Listed above, or Mark NA *

Female / Obstetrical History

Please Select All That APPLY * Describe (specific Name, Type, and Details) of ANY Birth Control (ANY FORM) You Are Using - or Mark NA *

Social / Substance History

CAFFIENE: Do you use Caffeine? *Check all that Apply * SMOKE or VAP: Do you smoke or Vape? * CHEWING TOBACCO: Do you use chewing tobacco? * ALCOHOL: Do you drink alcohol? **CHECK ALL THAT APPLY, BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details. OTHER DRUGS: Do you use ANY of the following drugs? **CHECK ALL THAT APPLY, BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details. * If "Other" Selected, Please List drug name and Dose or Amount you take or Mark NA * HOW OFTEN: If you selected any drugs listed above, How often are you taking them? *

IV / IM Nutritional or Hydration Therapy - Next (3) Sections

Main Physical and Emotional Complaints - IV Nutritional Therapies **(Please check all that apply)** * Which Statements Best Describe Why You Want an IV Infusion? **(Check all that apply)** What IV Infusion / IM Injection are you requesting or interested in? *

CHRONIC PAIN and/or PSYCHOSOCIAL TREATMENT ONLY - NEXT (12) SECTIONS

Chronic Pain - Locations and Pain Ratings

Select ALL locations of CHRONIC Pain you have below AVERAGE DAILY Pain * HIGHEST DAILY Pain *

Psychosocial / Mental Health

Select ALL Psychosocial conditions you have now or have been diagnosed with in the past * * If "Something Else" Selected above: List and give Details Please, Or Mark NA Hospitalizations: Have you EVER been hospitalized for ANY of the Above check marked Conditions? * If "Yes" Marked in Last Question: PLEASE EXPLAIN - Why and When you were Hospitalized or Mark "NA" *

Anti-Depression / Anti-Anxiety / Other Psychosocial Medication / Treatment History - Next (3) Sections

Have you Taken ANY of the Following Medications to Improve Your Mental Health **(Please check all that you have taken)** * IF Selected "OTHER MEDICATION NOT LISTED" above, Please LIST Below and EXPLAIN its Use.? or Mark N/A * Select ALL Reasons the Above Selected Medications DID NOT HELP You: * Have you received ANY of the following ALTERNATIVE TREATMENTS for Psychosocial Conditions? * AVERAGE DAILY Anxiety * HIGHEST DAILY Anxiety * HIGHEST DAILY Depression * AVERAGE DAILY Depression * How did you FIND US or HEAR ABOUT Wyoming Wellness Center? *

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ANY FURTHER INFO / COMMUNICATIONS ABOUT YOU?