This field is hidden when viewing the form
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
date copy
Patient's Last Name*
This field is hidden when viewing the form
Date of Birth*
MM slash DD slash YYYY
Date of Birth* This field is hidden when viewing the form
dateofbirth copy
Age*
This field is hidden when viewing the form
We apologize for the inconvenience, we only see patients 16 years of age or older. This field is hidden when viewing the form
Do you have an open legal case or court case? Workers Compensation or Child Protective Services (CPS) Hearing?* We apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment. This field is hidden when viewing the form
Are you already ON any pain-control medication such as Hydrocodone, Percocet, Tylenol w/ Codeine, Pain-controlling patches, Opioids, etc.? Please be advised that we will NOT be able to prescribe any Benzodiazepines such as Xanax, Klonopin, Valium, or Ativan due to DEA regulations.* Please contact our Appointment Team at 817-488-8998 ext 2 to further assist you. I understand that Mid Cities Psychiatry may request a Urine Drug Screen, which I must provide either at Mid Cities Psychiatry's office or at an accredited laboratory within 48 hours of their request. If the screen detects substances not prescribed (including THC, Delta 8, Kratom, and Alcohol) or if it shows a lack of prescribed medications, Mid Cities Psychiatry reserves the right to decline any further prescriptions.* This field is hidden when viewing the form
I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.* I acknowledge that eligibility for a FormFill Appointment requires a minimum of 5 previous appointments and an association with the clinic for at least 5 months. I will not request a FormFill Appointment if I do not meet these criteria, specifically if: I have been associated with the clinic for 5 months but have had fewer than 5 appointments, or I have had 5 appointments but my association with the clinic is under 5 months.* This field is hidden when viewing the form
I acknowledge Mid Cities Psychiatry's policy for rescheduling, canceling, and no-shows. I must inform Mid Cities Psychiatry at least 24 business hours before my appointment for changes. Weekends, long weekends, and national holidays are excluded as they are non-business hours. Non-compliance will incur charges as per the RCN Fee Schedule:
• 40 minutes meds management appointment no-show fees would be $150.00
An appointment Rescheduled or Canceled within 24 business hours of your appointment or No-Show at the appointment will be billed as per the following RCN Fee Schedule. Please be advised calls made 24 hours before the appointment on weekends or long weekends or on National Holidays when our offices are closed are not 24 Business Hours. So to avoid our billing department billing you RCN Fee, please call in more than 24 business hours.* RCN (Rescheduling / Cancellation / No-Shows) Policy:
My Contact Information Cell Number*
Home Number
Email*
Street Address*
This field is hidden when viewing the form
City*
State* Zip/Postal Code*
My Insurance Insurance Please upload your Identification Please select the type of identification you would like to use.* Select Option Driver’s License Government ID Passport/Passport Card
Please provide the front image of your identification in PDF or JPG format. Please provide the back image of your identification in PDF or JPG format.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load. This field is hidden when viewing the form
Primary Insurance Primary Insurance* Select Primary Insurance Aetna Allsaver Ambetter From Superior Health Plan American Behavioral Health Blue Cross Blue Shield Bright HealthCare Care Improvement Plan Care N Care Cigna CompSych GHI - BMP Golden Rule Group and Pension Administrator(GPA) HealthScope HealthSmart (Network) Humana Magellan Behavioral Health Medicare Molina Texas Healthcare Mulitiplan (Network) Mutual of Omaha Medicare Advantage Plan New Era Life Insurance PHCS (Network) Scott & White Health Plan Silver Back TPA Tricare East Region Tricare For Life Triwest UMR United HealthCare Other Insurance
Other Insurance*
This field is hidden when viewing the form
Primary Insurance ID #*
Primary Insurance Group #
Please upload your Insurance card Please provide the front image of your Insurance Card in PDF or JPG format. Please provide the back image of your Insurance Card in PDF or JPG format.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load. This field is hidden when viewing the form
Secondary Insurance Secondary Insurance Select Secondary Insurance N/A Aetna Allsaver Ambetter From Superior Health Plan American Behavioral Health Blue Cross Blue Shield Care Improvement Plan Care N Care Cigna CompSych GHI - BMP Golden Rule Group and Pension Administrator(GPA) HealthScope HealthSmart (Network) Humana Magellan Behavioral Health Medicare Molina Texas Healthcare Mulitiplan (Network) Mutual of Omaha Medicare Advantage Plan New Era Life Insurance PHCS (Network) Scott & White Health Plan Silver Back TPA Tricare East Region Tricare For Life Triwest UMR United HealthCare
Secondary Insurance ID #
Secondary Insurance Group #
Please upload your Identification Please select the type of identification you would like to use.* Select Option Driver’s License Government ID Passport/Passport Card
Please provide the front image of your identification in PDF or JPG format. Please provide the back image of your identification in PDF or JPG format.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load. This field is hidden when viewing the form
How Did You Hear About Us* Select Option Blog or Publication Customer Testimonials Referred by a Friend Referred by a Provider Referred by our Patient Search Engine (Google, Yahoo, etc.) Social Media (Twitter, Facebook, LinedIn)
Name*
Specialty*
Phone Number*
Fax Number*
Appointment Reason Appointment Reason* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Esketamine (Sparavto) Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
Other Reason*
Appointment Reason Description*
This field is hidden when viewing the form
PIF This field is hidden when viewing the form
Previous Psychiatric Diagnosis This field is hidden when viewing the form
Have you been previously diagnosed with a psychiatric disorder?* This field is hidden when viewing the form
This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Other Reason*
This field is hidden when viewing the form
Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-2 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Other Reason*
This field is hidden when viewing the form
Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-3 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Other Reason*
Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-4 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Other Reason*
This field is hidden when viewing the form
Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-5 This field is hidden when viewing the form
Diagnosis * Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
This field is hidden when viewing the form
Year Diagnosed * Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Other Reason*
This field is hidden when viewing the form
Previous Psychiatric Hospitalizations and/or Rehabilitation This field is hidden when viewing the form
Have you previously been hospitalized with a psychiatric disorder and/or attended a rehabilitation facility?* This field is hidden when viewing the form
This field is hidden when viewing the form
Hospital/Rehab Name*
This field is hidden when viewing the form
Year* Choose a year 1910
This field is hidden when viewing the form
Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-1 This field is hidden when viewing the form
Hospital/Rehab Name*
This field is hidden when viewing the form
Year* Choose a year 1910
This field is hidden when viewing the form
Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-2 This field is hidden when viewing the form
Hospital/Rehab Name*
This field is hidden when viewing the form
Year* Choose a year 1910
This field is hidden when viewing the form
Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-3 This field is hidden when viewing the form
Hospital/Rehab Name*
This field is hidden when viewing the form
Year* Choose a year 1910
This field is hidden when viewing the form
Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-4 This field is hidden when viewing the form
Hospital/Rehab Name*
This field is hidden when viewing the form
Year* Choose a year 1910
This field is hidden when viewing the form
Previous Psychiatric/Sleep Medications This field is hidden when viewing the form
Have you previously been prescribed any Psychiatric/Sleep Medications?* This field is hidden when viewing the form
This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-2 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-3 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-4 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-5 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-6 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
This field is hidden when viewing the form
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-7 This field is hidden when viewing the form
Medications Name*
This field is hidden when viewing the form
Dose*
Start Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
End Date *
MM slash DD slash YYYY
This field is hidden when viewing the form
Side Effects*
This field is hidden when viewing the form
Medication Allergies This field is hidden when viewing the form
Do you have any Medication Allergies?* This field is hidden when viewing the form
This field is hidden when viewing the form
Name*
This field is hidden when viewing the form
Reaction*
This field is hidden when viewing the form
Do you have an additional Medication Allergies?* This field is hidden when viewing the form
MA-2 This field is hidden when viewing the form
Name*
This field is hidden when viewing the form
Reaction*
This field is hidden when viewing the form
Pharmacy This field is hidden when viewing the form
Do you have a Pharmacy?* This field is hidden when viewing the form
This field is hidden when viewing the form
Name*
This field is hidden when viewing the form
City*
This field is hidden when viewing the form
State* This field is hidden when viewing the form
Phone #*
This field is hidden when viewing the form
Do you have an Additional Pharmacy?* This field is hidden when viewing the form
Pharmacy-2 This field is hidden when viewing the form
Name *
This field is hidden when viewing the form
City *
This field is hidden when viewing the form
State * This field is hidden when viewing the form
Phone #*
This field is hidden when viewing the form
Self Medical History This field is hidden when viewing the form
Do you have medical history (seizures disorders, diabetes, heart problems, other)?* This field is hidden when viewing the form
This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional medical history?* This field is hidden when viewing the form
SMH-2 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional medical history?* This field is hidden when viewing the form
SMH-3 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional medical history?* This field is hidden when viewing the form
SMH-4 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional medical history?* This field is hidden when viewing the form
SMH-5 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional medical history?* This field is hidden when viewing the form
SMH-6 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Physical Pain This field is hidden when viewing the form
Have you had physical pain in the last week?* This field is hidden when viewing the form
On this scale how bad was your pain? (0 is none and 10 is severe)* This field is hidden when viewing the form
Do you currenty have physical pain now?* This field is hidden when viewing the form
On this scale how bad was your pain? (0 is none and 10 is severe)* This field is hidden when viewing the form
Nutritional Status This field is hidden when viewing the form
1. Do you have food allergies?* This field is hidden when viewing the form
2. Have you had weight loss or gain of 10 pounds or more in the last 3 months?* This field is hidden when viewing the form
3. Have you had a decrease in food intake and/or appetite?* This field is hidden when viewing the form
4. Do you have dental problems?* This field is hidden when viewing the form
5. Do you have eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting?* This field is hidden when viewing the form
What are they?*
This field is hidden when viewing the form
Nutritional Status Score Is (this field is to be hidden)
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
You are identified as
This field is hidden when viewing the form
Self Psychiatric History This field is hidden when viewing the form
Do you have psychiatric history?* This field is hidden when viewing the form
This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-2 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-3 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-4 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-5 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-6 This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed* Choose a year 1910
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
This field is hidden when viewing the form
Have you ever experienced trauma?* This field is hidden when viewing the form
What trauma have you experienced?*
This field is hidden when viewing the form
Have you ever experienced abuse?* This field is hidden when viewing the form
What abuse have you experienced?*
This field is hidden when viewing the form
Have you ever experienced neglect?* This field is hidden when viewing the form
What neglect have you experienced?*
This field is hidden when viewing the form
Have you ever been exploited?* This field is hidden when viewing the form
How have you been exploited?*
This field is hidden when viewing the form
Family Medical History This field is hidden when viewing the form
Do you have biological family members with a medical history (seizures disorders, diabetes, heart problems, other)?* This field is hidden when viewing the form
This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-2 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-3 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-4 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-5 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-6 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-7 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-8 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-9 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-10 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Family Psychiatric History This field is hidden when viewing the form
Do you have any biological family members with psychiatric history?* This field is hidden when viewing the form
This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-2 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-3 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-4 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-5 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-6 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-7 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-8 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-9 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-10 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Past Surgical History This field is hidden when viewing the form
Have you had any surgeries in the past?* This field is hidden when viewing the form
This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
This field is hidden when viewing the form
Provider Name*
This field is hidden when viewing the form
Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-2 This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
This field is hidden when viewing the form
Provider Name*
This field is hidden when viewing the form
Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-3 This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
This field is hidden when viewing the form
Provider Name*
This field is hidden when viewing the form
Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-4 This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
This field is hidden when viewing the form
Provider Name*
This field is hidden when viewing the form
Legal History This field is hidden when viewing the form
Do you have a Current or Previous Conviction?* This field is hidden when viewing the form
This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Charge*
This field is hidden when viewing the form
Convicted*
This field is hidden when viewing the form
Sentence*
This field is hidden when viewing the form
Do you have an Additional Legal History?* This field is hidden when viewing the form
LH-2 This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Charge*
This field is hidden when viewing the form
Convicted*
This field is hidden when viewing the form
Sentence*
This field is hidden when viewing the form
Do you have an Additional Legal History?* This field is hidden when viewing the form
LH-3 This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Charge*
This field is hidden when viewing the form
Convicted*
This field is hidden when viewing the form
Sentence*
This field is hidden when viewing the form
Probation This field is hidden when viewing the form
Are you currently on Probation?* This field is hidden when viewing the form
This field is hidden when viewing the form
Parole?*
This field is hidden when viewing the form
Ending Date?
MM slash DD slash YYYY
This field is hidden when viewing the form
Lawsuits This field is hidden when viewing the form
Are you involved in any lawsuits?* This field is hidden when viewing the form
Court Dates This field is hidden when viewing the form
Do you have any upcoming Court Dates?* This field is hidden when viewing the form
This field is hidden when viewing the form
Reason
This field is hidden when viewing the form
Military Service This field is hidden when viewing the form
Do you have a Military Service?* This field is hidden when viewing the form
This field is hidden when viewing the form
What did you do?* This field is hidden when viewing the form
Type*
This field is hidden when viewing the form
How long did you serve?
This field is hidden when viewing the form
Was your Discharge Honorable or Dishonorable?* This field is hidden when viewing the form
Please explain*
This field is hidden when viewing the form
This field is hidden when viewing the form
Were you involved in a any combat?* This field is hidden when viewing the form
Please describe Combat experience*
This field is hidden when viewing the form
Are you troubled now by your military experience?* This field is hidden when viewing the form
Please describe your trouble by military experience*
This field is hidden when viewing the form
Previous Substance Abuse This field is hidden when viewing the form
Were you involved in Substance Abuse?* This field is hidden when viewing the form
This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Do you have an additional Substance Abuse?* This field is hidden when viewing the form
PSA-2 This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Do you have an additional Substance Abuse?* This field is hidden when viewing the form
PSA-3 This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Current Substance Abuse This field is hidden when viewing the form
Are you currently involved in Substance Abuse?* This field is hidden when viewing the form
This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
Age started?*
This field is hidden when viewing the form
Quantity*
This field is hidden when viewing the form
Do you have an additional Substance Abuse?* This field is hidden when viewing the form
CSA-2 This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
Age started?*
This field is hidden when viewing the form
Quantity*
This field is hidden when viewing the form
Do you have an additional Substance Abuse?* This field is hidden when viewing the form
CSA-3 This field is hidden when viewing the form
Name of Substance*
This field is hidden when viewing the form
Age started?*
This field is hidden when viewing the form
Quantity*
This field is hidden when viewing the form
Nicotine This field is hidden when viewing the form
Do you use nicotine products?* This field is hidden when viewing the form
This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
This field is hidden when viewing the form
Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Frequency*
This field is hidden when viewing the form
Do you use any other nicotine products?* This field is hidden when viewing the form
N-2 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
This field is hidden when viewing the form
Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Frequency*
This field is hidden when viewing the form
Do you use any other nicotine products?* This field is hidden when viewing the form
N-3 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
This field is hidden when viewing the form
Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
This field is hidden when viewing the form
Frequency*
This field is hidden when viewing the form
Do you use any other nicotine products?* This field is hidden when viewing the form
N-4 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
This field is hidden when viewing the form
Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using
This field is hidden when viewing the form
Frequency*
This field is hidden when viewing the form
Vape This field is hidden when viewing the form
Do you Vape?* This field is hidden when viewing the form
Drink This field is hidden when viewing the form
Do you drink alcohol?* This field is hidden when viewing the form
Alcohol Screening Questionnaire ( AUDIT ) Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below. This field is hidden when viewing the form
1. How often do you have a drink containing alcohol?* This field is hidden when viewing the form
2. How many drinks containing alcohol do you have on a typical day when you are drinking?* This field is hidden when viewing the form
3. How often do you have four or more drinks on one occasion* This field is hidden when viewing the form
4. How often during the last year have you found that you were not able to stop drinking once you had started?* This field is hidden when viewing the form
5. How often during the last year have you failed to do what was normally expected of you because of drinking?* This field is hidden when viewing the form
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?* This field is hidden when viewing the form
7. How often during the last year have you had a feeling of guilt or remorse after drinking?* This field is hidden when viewing the form
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?* This field is hidden when viewing the form
9. Have you or someone else been injured because of your drinking?* This field is hidden when viewing the form
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?* This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using
This field is hidden when viewing the form
Are you currently, or have you previously received treatment for an alcohol problem?* This field is hidden when viewing the form
This field is hidden when viewing the form
Have you ever been in treatment for an alcohol problem?* Never Currently In The Past
This field is hidden when viewing the form
Currently This field is hidden when viewing the form
At what location?*
This field is hidden when viewing the form
Frequency of visit*
This field is hidden when viewing the form
When was the last time you had an alcoholic drink?*
This field is hidden when viewing the form
In the past This field is hidden when viewing the form
At what location?*
This field is hidden when viewing the form
What year? Choose a year 1910
This field is hidden when viewing the form
When was the last time you had an alcoholic drink?*
This field is hidden when viewing the form
Social History/Marital Status This field is hidden when viewing the form
Marital Status* Please choose your marital status Single Married Divorced Seperated Widowed
This field is hidden when viewing the form
Social History/Sexual Orientation This field is hidden when viewing the form
Sexual Orientation* Please choose your sexual orientation Asexual Bisexual Gay Heterosexual Lesbian Pansexual
This field is hidden when viewing the form
Gender This field is hidden when viewing the form
Gender* Please choose your gender Male Female Transgender Gender Neutral Non-Binary Choose Not to Disclose
This field is hidden when viewing the form
Education This field is hidden when viewing the form
Have you completed your education?* This field is hidden when viewing the form
This field is hidden when viewing the form
Highest Schooling* Choose your highest schooling High School/GED Associates Bachelors Masters PhD MD/DO
This field is hidden when viewing the form
Employment This field is hidden when viewing the form
Are you Employed?* This field is hidden when viewing the form
This field is hidden when viewing the form
Type of Employment Choose your employment status Full Time Part Time
This field is hidden when viewing the form
Company Name
This field is hidden when viewing the form
Occupation*
This field is hidden when viewing the form
This field is hidden when viewing the form
Not-Employed* Choose your option Disabled Retired Unemployed
This field is hidden when viewing the form
Physical Exam Self Assessment This field is hidden when viewing the form
Please rate your Thought Process* Choose your thought process Good Fair Poor
This field is hidden when viewing the form
Please rate your Long Term Memory* Choose your long term memory Good Fair Poor
This field is hidden when viewing the form
Please rate your Short Term Memory* Choose your short term memory Good Fair Poor
This field is hidden when viewing the form
Please rate your Concentration* Choose your concentration Good Fair Poor
This field is hidden when viewing the form
Suicidal Ideations This field is hidden when viewing the form
Are you having Suicidal Ideations?* This field is hidden when viewing the form
Do You Have a Plan?* This field is hidden when viewing the form
What is your plan?*
This field is hidden when viewing the form
Homicidal Ideations This field is hidden when viewing the form
Are you having Homicidal Ideations?* This field is hidden when viewing the form
Do You Have a Plan?* This field is hidden when viewing the form
What is your plan?*
Scheduling Your Appointment! Meeting your needs is our top priority. If you don't receive a response from us within 24 business hours, please feel free to reach out
only once , 
