Patient Forms

New Patient Information

Name*

Date of Birth*

Current Age*

Partner Status*

Race*

Gender

Select valuemalefemaleother

Preferred pronouns

Select valuehe/himshe/herthey/themother

Current medications, doses, and when each is due to run out*

Mailing address*

City*

State

Zip*

Cell Phone*

Home Phone*

Is it OK to leave a message?*

Select valueYesNo

Email*

Emergency Contact*

Emergency Contact Relationship*

Emergency Contact Cell Phone*

Emergency Contact Email Address*

Pharmacy name, location, and phone number*

Lab you use for blood work*

Name of your medical doctor*

Type of Doctor*

Select valueInternal MedicineFamily Medicine

Names of other medical specialists you see*

Name of your therapist (if you have one)*

Who referred you to WPH?*

PLEASE ANSWER AND EXPLAIN IF NEEDED

Active suicidal thoughts

Yes

No

Suicidal thoughts explain

Active psychotic thoughts

Yes

No

Psychotic thoughts explain

Active substance abuse

Yes

No

Substance abuse explain

Active legal issues

Yes

No

Legal issues explain

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