New Patient Form (TocDoc)
New patient intake form
Email address *
Patient's full name *
Your answer
Patient's age (in years) *
Your answer
Patient's date of birth *
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Patient's sex *
Patient's phone number *
Your answer
Patient's mailing address, City, State, Zipcode *
Your answer
Patient's insurance (Payer name) *
Patient's insurance (Plan name and type) *
Who is the primary member of patient's insurance plan (name and address) *
Your answer
Patient's insurance (Member ID) *
Your answer
Patient's insurance (Group ID) *
Your answer
Patient's insurance (Effective date) *
Your answer
Patient's insurance (office Visit Copay) *
Your answer
Patient's insurance (Relationship to Insured) *
Patient's emergency contact (name, phone number, relationship) *
Your answer
Patient's marital status *
Employment status *
Highest level of education *
Your answer
Have you served in the military *
Primary care physician (name, phone number, email, fax) *
Your answer
Current therapist (name, phone number, email, fax) *
Your answer
What is the patient seeking our help for? *
Your answer
What are the patient's current medications? (names, dosage, reason it was prescribed) *
Your answer
What allergies does the patient have? (name the allergen and the reaction) *
Your answer
Current mental health diagnosis *
Your answer
Current mental health treatment *
Your answer
Have you ever been in a psychiatric hospital? When and what led to the hospitalization (s)? *
Your answer
Have you ever attempted suicide? What method did you use? *
Your answer
How you ever harmed someone else? What was the consequence of your behavior? *
Your answer
Current medical conditions *
Your answer
Previous surgeries *
Your answer
Smoking status *
How many caffeinated beverages do you drink per day? *
Are you currently using any of these? *
Required
Do you have any active legal issues? *
Are you adopted? *
Does anyone else in your family have mental illness? If so, who and what is there diagnosis? *
Your answer
Has anyone in your immediate family attempted suicide? Who and what was the consequence? *
Your answer
Is there anything else in particular that you want the doctor to know about you? *
Your answer
Who filled this form? *
Date this form was filled *
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