Request edit access
Patient Intake Form
Please answer the questions below to your best ability. If you have any questions about how to answer the form, please contact us by either emailing us at dr.garyzhou@gmail.com or calling us at 754-220-6799.
Email address *
Patient's Name: *
Your answer
Phone Number: *
Your answer
Date of Birth: *
Your answer
Gender: *
Nationality/Ethnicity: *
Your answer
Have you traveled outside of the US in the last 30 days? If so, where? *
Your answer
Marital Status: *
Education level (Please listed highest achieved): *
Your answer
Current employment status (within the last 30 days): *
Your answer
How did you hear about our treatment services? *
Required
Have you ever sought treatment for drug/alcohol use? If so, how many times, and where the treatments provided in-patient or out-patient? *
Your answer
Have you been admitted to a treatment facility within the past calendar year? *
Your answer
What is the main substance for which you are seeking treatment? *
Your answer
What is the secondary substance for which you are seeking treatment, if any? *
Your answer
How have you most frequently administer the substance you are seeking treatment for within the last 30 days? *
Required
If you checked "other", please specify below. *
Your answer
What age where you when you started to use this drug? *
Your answer
Please check any and all drugs you have used within the past 30 days below: *
Required
Please list all other psychoactive substances you have used in the past 30 days (not mentioned above): *
Your answer
Have you ever been arrested? *
If yes, have you been arrested in the past year? *
If yes, how many times were you arrested in the last year? *
Your answer
Have you ever been treated for psychiatric conditions? If yes, which conditions? *
Your answer
Have you ever been tested for any of the following diseases? (check all that apply) *
Required
What were the results of these tests? *
Your answer
Are you currently in treatment? *
When would you be able to begin treatment? *
MM
/
DD
/
YYYY
What is your preferred time to schedule your appointment? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service