New Patient Intake Questionnaire
We are excited to have you join Kansas City Direct Primary Care!

You filled out a medical history questionnaire when you signed up with us. This questionnaire has a few more questions that we feel are important beyond the usual health intake questions.

You may have answered some of these during the initial enrollment. If you feel you've answered these questions adequately before, you can put "see enrollment form" in the blank. If you didn't fill out the blanks in the enrollment form, now's your chance!

This form and the answers you submit are encrypted to protect your privacy. For more information about our privacy practices, please see our

First name *
Your answer
Last name *
Your answer
Email Address or Phone Number (Your preferred means of contact):
Your answer
Date of birth *
MM
/
DD
/
YYYY
Do you currently have health insurance?
Did your last primary care provider take insurance? *
Regarding your spending on healthcare over the last 12 months, how much did you spend out-of-pocket on: *
$0
$1 - $100
$101 - $500
$501 - $1000
$1001 - $2000
$2001 - $5000
Over $5000
I have no idea.
Doctor's visits?
Emergency Room Visits?
Hospital bills?
Laboratory testing?
Radiology? (X-Rays, CAT scans, MRIs, etc.)
Medications?
Medical Equipment? (Wheelchairs, assistive devices, etc.)
Other medical expenses?
How did you hear about us? *
Required
Did a current KCDPC member refer you to our practice? If so, who was it? We want to thank them.
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Kansas City Direct Primary Care. Report Abuse - Terms of Service - Additional Terms