sparkMD New Patient Form

Name:__________________________________________________

Birthdate:__________________________ Age:_________________

Address:________________________________________________

City:___________________State:_________ Zip:_______________

Cell Phone:_(______)_________________ Carrier: ______________

Other Number:_(______)____________________ Email:__________________________________________________

⬜ Ok to contact ⬜ Ok to leave DETAILED message

How did you hear about us?__________________________________________________________________________

Would you like to share your health information with someone?:______________________________________________

You may revoke this permission at any time by calling 208-369-4590.

Prior Primary Care Doctor:_______________________________ Other Providers:_______________________________

Preferred Pharmacy:________________________________________________________________________________

Do you have insurance/ a health sharing ministry? ⬜ Yes ⬜ No

Please give us your insurance card to copy if you ever want labs, or imaging billed to them.

What are your goals today?___________________________________________________________________________

MEDICAL PROBLEMS (PAST OR PRESENT):

Seizures	Thyroid Problems	High Blood Pressure	Weight Problems
Stroke or mini-stroke	COPD / Emphysema	High Cholesterol	Eating Disorder
Head Injury	Seasonal allergies	Heart Problems	Depression or Anxiety
Migraines or chronic headaches	Sleep apnea	Diabetes or pre-diabetes	Psychiatric Illness
Memory loss / Alzheimer's	GERD / heartburn	Blood clots	Insomnia
Neuropathy/nerve issue	Ulcers or bleeding	Numbness or Tingling	Alcohol / Drug Addiction
Autoimmune disease	Diverticulosis/litis	Orthopedic Injury	Easy Bruising / Bleeding
Hepatitis or HIV	Colon Problems	Abnormal Pap Smears	Easy Scarring / Keloids
Eye Problems	Hemorrhoids	Erectile Dysfunction	Cancer (type):
Hearing Problems	Chronic Pain	Genital Herpes

Is there anything else you would like us to know about your medical history? ____________________________________

_________________________________________________________________________________________________

For women: Are you possibly pregnant and/or breastfeeding? ⬜ Yes ⬜ No

SURGICAL HISTORY & HOSPITALIZATIONS: ALLERGIES: ⬜ NO MEDICATION ALLERGIES

_______________________________________ ⬜ PENICILLIN ⬜ SULFAS ⬜ LATEX

_______________________________________ OTHER_______________________________________

_______________________________________ SENSITIVITIES: ⬜ NO MEDICATION SENSITIVITIES

MEDICATION & SUPPLEMENTS:

Name Dose Frequency Name Dose Frequency

1.				6.
2.				7.
3.				8.
4.				9.
5.				10.

HABITS:

What do you do for exercise? ___________________________ How often?____________________________________

Do you smoke? ⬜ Yes ⬜ No Have you ever smoked for more than 1 year? ⬜ Yes ⬜ No

If yes- how many years did you smoke? _________________ How many packs per day? ___________________

How many glasses of beer, wine or hard liquor do you drink in an average week? None, 1-3, 3-5, 5-7, 7-10, 10 or more.

Have you ever had an addiction to prescription medication: ⬜ Yes ⬜ No

Have you ever used illegal drugs: ⬜ Yes ⬜ No

If yes- are you presently taking medications not prescribed for you, buying or getting medications outside of a physician and/or do you believe this is something you need help with? ⬜ Yes ⬜ No

Do you follow a particular eating plan (keto, paleo, gluten free, no dairy etc??)___________________________________

Is there anything else you would like us to know about your medical care or personal philosophy about your healthcare?

_________________________________________________________________________________________________

FAMILY HISTORY:

What medical problems run in your FIRST degree relatives? (your mother, father, siblings, children)?

__________________________________________________________________________________________________________________________________________________________________________________________________

WELLNESS SCREENING: When was your last (put dates to right of item, please)

Labs/Cholesterol test	Colonoscopy	Flu Shot
Dental Exam	Mammogram (women)	Tetanus Shot (Td or TdaP)
Eye Exam	Pap Smear (women)	Shingles Shot(s)
Prostate Test (PSA) (men)	Bone Density (DEXA) - (women)	Pneumonia Shot(s)

I was offered a copy of HIPAA (Government Privacy Policies).
I understand sparkMD is NOT insurance and does not send any claims to insurance companies.
I understand that I will be billed monthly for sparkMD services, whether I have a patient visit or not.
I understand that sparkMD is a collaborative practice and that the physician (MD), Nurse Practitioner and Physician Assistant work together to care for all members.
sparkMD is an educational site for the University of Utah School of Medicine and Idaho State University Physician Assistant program and these students may accompany Dr. Julie or Erin as scribes during my visit.

Signature: ________________________________________________