Patient Health History
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Which best describes the services seeking? *
Your information will not be shared
How soon do we need to get you an appointment? *
Please check all that apply - (We will send you an email to get your approval before scheduling)
Required
Describe briefly your present symptoms... *
Name *
First, Last name
Sex *
Birth date *
Please provide accurate DOB as it is used to create your Medical Record (your information will not be shared)
MM
/
DD
/
YYYY
Phone number (plus area code) *
Are you living in Texas? *
City *
Zip *
Street Address *
List any Medication ALLERGIES? *
List any MEDICATIONS you are currently taking?
GENERAL:  Do you suffer from any of the following issues?  (Recent weight gain, Recent weight loss, Dizziness, Fatigue, Weakness, Fever, Night sweats)
MUSCLE/JOINTS/BONES: Do you suffer from any of the following issues?  (Numbness, Joint pain, Muscle weakness, Joint swelling)
EARS: Do you suffer from any of the following issues?  (Ringing in ears, Loss of hearing)
EYES: Do you suffer from any of the following issues?  (Pain, Redness, Loss of vision, Double or blurred vision, Dryness)
THROAT: Do you suffer from any of the following issues?  (Frequent sore throats, Hoarseness, Difficulty in swallowing, Pain in jaw)
HEART AND LUNGS: Do you suffer from any of the following issues?  (Chest pain, Palpitations, Shortness of breath, Fainting, Swollen legs or feet, Cough)
NERVOUS SYSTEM: Do you suffer from any of the following issues?  (Headaches, Dizziness, Fainting or loss of consciousness, Numbness or tingling, Memory loss)
STOMACH AND INTESTINES: Do you suffer from any of the following issues?  (Nausea, Heartburn, Stomach pain, Vomiting, Yellow jaundice, Increasing constipation)
SKIN: Do you suffer from any of the following issues?  (Pain, Redness, Rash, Nodules/bumps, Hair loss, Dryness, Color changes of hands or feet)
BLOOD: Do you suffer from any of the following issues?  (Anemia or Clots)
KIDNEY/URINE/BLADDER: Do you suffer from any of the following issues?  (Frequent or painful urination, Blood in urine)
PSYCHIATRIC: Do you suffer from any of the following issues?  (Depression, Insomnia, Thoughts of suicide or attempts, Anxiety, Poor concentration, Racing thoughts, Hallucinations, Paranoia, Mood swings)
WOMAN ONLY: Do you suffer from any of the following issues?  (Abnormal Pap smear, Irregular periods, Bleeding between periods, Currently pregnant)
OTHER: Do you suffer from any other issue not described above?
Do you now or have you ever had?
ALCOHOL: Please describe your use...
CANNABIS: Please describe your use...
OPIOIDS (heroin, methadone, Norco, Oxy's, Percocet, Morphine, Dilaudid): Please describe your use...
OTHER CURRENT DRUG USE: (other than listed above)
PAST DRUG USE: (other than listed above)
Our Clinic Guidelines
Must take medication as prescribed at all times.

Running out of medication early will result in the possibility of suffering withdrawals from some medications.

No extra refills are given in between appointments.

Patients must safe guard their medications.  A lock-box or safe maybe necessary to protect medications.

Even though medications can be beneficial there are always the possibility of side-effects and health risks.

Provide honest and truthful information at all times to the Prescriber.

Telemedicine is not perfect, at times there maybe disruptions.  Every effort will be made to reestablish the communication as soon as possible.

 That the regular abuse of drugs while on controlled prescriptions may result in discharge from the clinic.

Patients maybe required to give Urine Drug Screens on request of the Prescriber and/or randomly.

Laboratory testing, (UDS and bloodwork) are done at Quest Diagnostic Service Centers at patient cost.

Payment for Services must be arraigned and processed prior to the actual appointment.

An emergency (including suicidal thoughts) that occurs 'after hours' (prior to 9am or after 5pm) should be fulfilled by an emergency facility or call 911 operator.  All serious medical issues should immediately call 911 regardless of the hour.

If a patient has serious side effects they should stop the medication in question and call or email our office.

Email is the best contact method, followed by text messages and phone calls (during business hours) All communication methods will be answered as quickly as possible, even after hours if needed.

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