thriveMD - New Patient Intake Form
All information contained within is strictly confidential as according to HIPAA standards. Please complete all information at least 24 hours before appointment.

NOTE: Payment is due at time of service. thriveMD does not work with any insurance companies, therefore no CPT or ICD codes are provided.

Email address *
First Name, Last Name *
Address, City, State, Zip *
Birthdate *
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Occupation
Home Phone Number
Cell Phone Number *
Work Phone Number
Person to notify in case of emergency (name and phone number) *
How did you hear about thriveMD *
Reason for seeing us today? *
What are your top 3 health concerns? *
How would you rate your current health overall? *
Poor
Excellent
Date of your last physical exam?
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Primary doctor's name? *
Primary doctor phone number: *
Past Medical History
List all illnesses you have had requiring hospitalization including the date/year:
Describe any other serious injuries or accidents you have had:
Past Surgical History
List any operations you have had including date/year:
Medications
Check if currently taking or have taken in the past:
List any and all medications or supplements/vitamins you are currently taking: *
Allergies - Are you allergic to any drugs? If yes, please list drug(s) and describe reaction: *
Family History
Please select any of the following diseases that run in your family: *
Required
Specify relative that is associated with the disease(s) or illness (father, grandmother, etc.)
Social History
Do you smoke? *
Required
How much do you smoke per day?
Do you drink coffee *
Required
How many cups of coffee per day do you drink?
Do you drink alcohol? *
Required
How often do you drink alcohol per day/week?
Do you have trouble sleeping? *
Required
If you have trouble sleeping, please explain:
Women Only
Are still having regular monthly menstrual periods?
If yes, date of last menstrual period. If no, what year did your cycles end?
MM
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DD
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Do you have bad PMS symptoms before your period?
Do you get regular screening tests for breast and cervical cancer?
How many children do you have?
Do you have concerns or problems with sexual function?
Men Only
Have you ever received treatment for your genitals (private area)?
Do you receive regular screening tests for your prostate?
Do you have concerns or problems with sexual function?
General Health
Do you frequently experience any of the following:
Bleeding Gums? *
Required
Trouble swallowing or hoarseness? *
Required
Severe headache (migraines)? *
Required
Swelling in the ankles? *
Required
Nausea and vomiting? *
Required
Pain in the big toe?
General Health
Have you ever experienced any of the following:
Fainted? *
Required
Had spells of dizziness? *
Required
Had ringing or pain in your ears? *
Required
Burning while urinating? *
Required
Kidney Stones? *
Required
Had pain in the calves while walking? *
Required
Had a seizure? *
Required
Had double vision? *
Required
Nosebleeds? *
Required
Had blood in the urine? *
Required
Had cramps in your legs at night? *
Required
Have you ever had tightness or pain in your chest? (If yes, please explain)
Have you ever been short of breath while doing normal activity? (If yes, please explain)
Please provide any other relevant information about your current or past medical history here:
Would you be interested in learning more about any of the following services:
Submit
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