Screening Intake Form Name * First Name Last Name Email * Address * Date of Birth * MM DD YYYY Phone * (###) ### #### Relationship Status * Single In a Partnership Married Divorced Widowed What brings you to our medical clinic? * Are you seeking treatment for any of the following? (check all that apply) * Depression Anxiety Post Traumatic Stress Disorder Chronic Pain Current Mental Health Professional * Mental Health Professional Phone (###) ### #### Other Mental Health History * Medical History * Medications * Surgical History * Have you ever experienced an adverse reaction to anesthesia? * No Yes List Any Known Allergies * Alcohol Consumption * Never/Rarely Couple Drinks per Month Couple Drink per Week One Drink a Day Several Drinks a Day Have you ever received treatment for substance abuse disroder? Yes No Never received treatment but I do struggle with addiction Please use this space to share your past and current substance use history including marijuana and other substances: Diet (Select One) * Vegan (No Animal Products) Vegetarian (dairy ok) Pescatarian (fish ok) Omnivor (meat ok) Exercise (select one) * Every Day 3-4 Times/Week 1-2 Times/Week Several Times/Month Rarely Physical Activity (select all that apply) * Yoga Pilates Running Walking Biking Weights Other How did you hear about us? * Mental health professional Friend Internet search Advertisement Social media Other Emergency Contact * Emergency Contact Phone Number * (###) ### #### Is there anything else you would like to share? * Thank you!
