PATIENT DEMOGRAPHICS
General Details
First Name: *
Middle Name:

Last Name: *
DOB:
(MM/DD/YYYY)
       * 
Gender: *
Select Image:

      
      
Gender Identity: *
Sexual Orientation: *
SSN:  
Preferred Language:
(With ISO 639-2 alpha 3 code) *




































































































































































































































































































































Race: *





Ethnicity: *


Practice Name: *
 
Provider Details
Provider:   *
Practice Name:  
Address Details
Street 1: *
Home Phone: *
Street 2: Mobile Number: *
City: *
Work Phone:  
Enter valid number
State: * Emergency Contact Number:
Zip Code: *
Emergency Contact Name:
Email ID: *  
Guarantor Details

Same as Patient Details
First Name:
Street 1:
Middle Name:  
Street 2:
Last Name:
City:
DOB:
(MM/DD/YYYY)
 
State:
Gender:
Phone:
Relationship: Zip Code:

Notes: Label
 
Insurance Details
Primary Insurance:   Policy Number:
Secondary Insurance:   Policy Number:
Group Name: Group Number:
Preference
Communication Preference
my PHI (protected health information) with anyone other than myself
to discuss my PHI (protected health information) with the following person(s):
It is acceptable to
my workplace.
my workplace.
to leave a message: A MESSAGE
with the person(s) listed above,
on my answering machine at home,
on my voice mail at work.
Patient Health information
What is your Height:     (0'0) Inches
What is your weight:     lbs
Last BP measurement:     /     (Systolic/Diastolic)
Last blood sugar:  
PHQ-9 for Adolescents
Instructions: How often have you been bothered by each of the following symptoms during the past 7 days?
S.No Questionnaires (0)
Not at all
(1)
Several days
(2)
More than half the days
(3)
Nearly every day
Item score
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself—or feeling that you are a failure, or that you have let yourself or your family down?
7. Trouble concentrating on things like school work, reading, or watching TV?
8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
Total/Partial Raw Score:
Prorated Total Raw Score: (if 1-2 items left unanswered)