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Primary Telehealth Form

Need Help Immediately? Dial 988

First Name: *

Middle Name:

Last Name: *

What name do you go by:

Email Address *

Password *

Confirm Password *

Phone Number *

Address:

City:

State:

Zip Code:

Birthdate:

Gender:

Male

Female

Transgender

Gender not listed

Race Ethnicity:

Time Zone:

Language:

Age:

Number of People in your House :

Household Annual Income:

Relationship Status:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Email:

Emergency Contact Phone Number:

What type of Primary Healthcare Support are you looking for? (Check all that apply )

A. Sick Visit

B. Medication refill (non-narcotic)

Do you have the following?

Medicaid

Medicare

Other

Work excuse/note:

Yes

School/ChildCare excuse/note:

Yes

Stomachache in left or right lower region or no bowel movement (poop) in more than 5 days ( GO TO THE EMERGENCY ROOM)
Chest pain and/or difficulty breathing ( GO TO THE EMERGENCY ROOM)
Pregnant (GO TO THE EMERGENCY ROOM)

Personal History

1. What is your highest level of education

2. What is your current occupation?

Student

Unemployed

Disabled

Employed

3. What do you like to do for fun?

4. Do you currently drink alcohol?

Yes

5. Do you smoke cigarettes or use drugs?

Cigarettes

Drugs

Both

6. Legal Issues past, current, or pending?

Yes

7. Primary Care Physician?

Yes

Symptoms

Patient Health Questionnaire (PHQ 9)

Over the last 2 weeks, how often have you been bothered by the following problems?		Not at all	Several Days	More than half the days	Nearly every day
1	Little interest or pleasure in doing things	0	1	2	3
2.	Feeling down, depressed, or hopeless	0	1	2	3
3.	Trouble falling asleep or sleeping too much	0	1	2	3
4.	Feeling tired or having little energy	0	1	2	3
5.	Poor appetite or overeating	0	1	2	3
6.	Feeling bad about yourself- or that you are a failure or have let yourself or family down	0	1	2	3
7.	Trouble concentrating on things, such as reading the newspaper or watching television	0	1	2	3
8.	Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual	0	1	2	3
9.	Thoughts that you would be better off dead, or of hurting yourself in some way	0	1	2	3
	TOTAL SCORE (add the marked numbers):	Total:

Family History

1. Check the conditions that apply to you or any of your immediate relatives:

Asthma

Cancer

Cardiac disease

Diabetes

Hypertension

Psychiatric disorder

Epilepsy

Other

N/A

2. Has anyone been diagnosed with anything in your family?

Yes

3. Please describe your relationship with your biological mother.

4. Please describe your relationship with your biological father.

5. Do you have siblings?

Yes

6. What is your current living situation?

Houseless

Self

With a Significant Other

With a Friend or Family Member

With Children

8. If you are in a relationship, please describe the nature of the relationship and length of time together.

9. What else would you like your Primary Healthcare Provider to know?

Completing this section below helps us to determine the Primary Healthcare provider that meets your needs:

Schedule (Check all that apply)

8am - 5pm

3pm - 11pm

11pm - 7am

Language