New Patient Medical History
Intake Form
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Email *
What is today's date? *
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First Name
Last Name
Please indicate your pronouns.
What is your date of birth: *
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Phone Number *
Please enter 10 digit phone number (example: 123-456-7890)
What is your home address? *
Height *
Please enter height in feet ' and inches " (Example: 5' 4")
Weight *
Are you able to read and understand English? *
How did you hear about drivePT ? We would love to know how you learned about drivePT!
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Are you currently seeing another healthcare provider for the reason you are seeking care?
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Are you latex sensitive?
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Do you smoke?
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Do you have any allergies?
Please list any allergies or medication(s) you are allergic to.
Any recent change in diet or physical activity levels? *
How many hours do you sleep on average per week? *
How much protein do you consume each day? *
Have you noted any of the following (check all that apply)? *
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Have you ever been diagnosed with any of the following conditions (check all that apply)? *
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Has anyone in your immediate family (parents, brother, sisters) EVER been diagnosed with any of the following conditions (check all that apply)? *
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During the past 2 weeks have you been feeling down, depressed or hopeless? *
During the past 2 weeks have you been bothered by having little interest or pleasure in doing things? *
Is this something with which you would like help?
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Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way?
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FOR WOMEN: Are you currently pregnant or think you might be pregnant?
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