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
Additional Information
Medical History
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
Please be detailed as this will guide us in your care and for IV Nutrition or Limitations to our treatments
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
Surgical History
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
**BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details.
Please select all that apply
Social / Substance History
Please be honest. We are not judging, we just want to keep you safe as some medications we provide can interact with these drugs.
(If Applicable)
Please be honest. We are not judging, we just want to keep you safe as some medications we provide can interact with these drugs.
ALONG WITH SELECTING THE FORM OF MARIJUANA YOU ARE TAKING, ALSO SELECT THE THC % FOR EACH FORM OF MARIJUANA YOU ARE TAKING
Please give details about the drugs used.<br/><br/>Please be honest. We are not judging, we just want to keep you safe as some medications we provide can interact with other drugs
**CHECK WHAT APPLIES, BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details.
IV / IM Nutritional or Hydration Therapy - Next (3) Sections
CHRONIC PAIN and/or PSYCHOSOCIAL TREATMENT ONLY - NEXT (12) SECTIONS
Chronic Pain - Locations and Pain Ratings
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
0 being NO Pain, 10 being UNBEARABLE Pain
0 being NO Pain, 10 being UNBEARABLE Pain
Psychosocial / Mental Health
Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification.
Please Describe Below
Anti-Depression / Anti-Anxiety / Other Psychosocial Medication / Treatment History - Next (3) Sections
0 being NO Anxiety, 10 being PARALYZING Anxiety
0 being NO Anxiety, 10 being PARALYZING Anxiety
0 being NO Depression, 10 being PARALYZING Depression
0 being NO Depression, 10 being PARALYZING Depression