OFFICE USE ONLY: Date of Intake: ID#: Staff mbr: Personal Information Full Name: Address: _ Last First M.I. Street Address Apartment/Unit # City State Zip Code County Date of Birth: Age: Mobile phone? Ok to leave a Message? Primary Phone: Yes No Provider Yes No Alternate Phone: Yes No Provider Yes No Email Address: Okay to send email? Yes No Please note, email is not secure and minimal information will be sent electronically. Gender: Male Female Other (specify) Race/Ethnicity: (Circle all that apply) American Indian/ Asian/ Black/ Hispanic/ Alaska Native South Asian African American Latino Native Hawaiian/ White/ Pacific Islander Caucasian Other: Are you a registered sex offender? Yes No How did you hear about us? Please explain (who, where, when, etc)
Emergency Contact Information Full Name: Address: Last First M.I. Street Address Apartment/Unit # City State Zip Code County Relationship to Patient: Mobile phone? Ok to leave a Message? Primary Phone: Yes No Yes No Alternate Phone: Yes No Yes No Military Background - Patient Did you serve in the United States military? Yes No Are you currently active duty? Yes No N/A If No, please skip to the Military Background Family Member section on the next page. Military Branch: Were you in the Reserves? Yes No Were you in the National Guard? Yes No Military rank: Occupational Specialty: Military service dates: From / / To / / Are you a post 9/11 Veteran? Yes No Did you serve in or in support of recent conflicts? (Check all that apply) Operation New Dawn (Sep 10 Dec 11) Yes No Operation Enduring Freedom (Oct 01 Dec 14) Operation Iraqi Freedom (Mar 03 Nov 11) Other: Military discharge status: Honorable General Other than honorable N/A
Did you receive a DD 214 Yes No Are you enrolled in VA Health care? Yes No Do you receive any of the following VA benefits? Primary Health Care Yes No N/A Mental Health Care Yes No N/A Prescription Health Care Yes No N/A HUD/VASH Yes No N/A Specialty Care? Yes No N/A If yes, what specialty? Military Background Family Member Did your family member serve in the United States military? Yes No Currently Active duty? Yes No If yes, which family member? Military rank: Occupational Specialty: Military service dates: Is your family member a post 9/11 Veteran? Yes No Did they serve in or in support of recent conflicts? (Check all that apply) Operation New Dawn (Sep 10 Dec 11) Yes No Unknown Operation Enduring Freedom (Oct 01 Dec 14) Operation Iraqi Freedom (Mar 03 Nov 11) Other: Military discharge status: Honorable General Other than honorable N/A Did they receive a DD 214 Yes No Unknown Enrolled in VA Health care? Yes No Unknown Does your family member receive any of the following VA benefits? Primary Health Care Yes No Unknown Mental Health Care Yes No Unknown Prescription Health Care Yes No Unknown HUD/VASH Yes No Unknown Specialty Care? Yes No Unknown If yes, what specialty? Personal Background Information
Marital Status: (Circle all that apply) Now Married Divorced Separated Widowed Never Married Living with partner Other: Highest level of education completed: (Circle one) Less than high school High school Associates degree College degree Post college degree Other: What is your annual household income? $ How much of your annual household income comes from wages? $ How much of your annual household income comes from subsidies (e.g., disability benefits/social security/tanf/other support)? $ Please select which subsidies: VA Disability Benefits TANF SSDI Other: Current employment status: (Circle one) Full-time Part-time Unemployed Do not work Other: Employer? Who currently resides in your home? Name Age Relationship to Patient
Are there any firearms in your home? Yes No Name and contact info of primary physician: Medical History Date of last physical exam: Name and contact info of other medical providers: Do you have any chronic illnesses or current physical problems? Yes No Do you smoke? Yes No Is there any family history of significant medical problems? Yes No Are you taking any prescription or non-prescription medications? Yes No If yes: Type of Medication Dose size Dose frequency In the past 2 weeks, were there any changes in medication? Yes No If YES, what were the changes? How often do you miss a dose of your medications? Have you noticed any side effects of your medications? Mental Health History Have you ever received counseling, psychological, or psychiatric treatment? Yes No Type of treatment (Inpatient, Where did you Type of problem Outpatient, Medication only) Length of treatment (Dates) receive treatment?
Were you satisfied with the treatment? Yes No Are you currently receiving counseling, psychological, or psychiatric treatment? Yes No If yes, please explain: Is there any family history of mental health concerns (e.g. depression?) Yes No If yes, please explain: In the past 3 months, have you been experiencing pain that interferes with your normal Activities on more than half the days each month? Yes No If yes, please rate your pain by circling the number that best describes your pain in the last 24 hours: 10 1 As bad as you No pain 2 3 4 5 6 7 8 9 can imagine How much has your pain interfered with your normal activities (including work outside and inside the house)? 1 10 No Complete Interference 2 3 4 5 6 7 8 9 interference Do you need additional help with your pain? Yes No Insurance Your insurance will NOT be billed for today s visit. The following questions are for informational purposes only: Do you currently have health insurance? Yes No If yes, what type of health insurance? In the future, if the option was presented to have your treatment billed to your insurance, would you be willing to use this option? Yes No