Texas Patient Intake Form First Name * Middle Name Last Name * Birthday (mm/dd/yyyy) * Social Security Number * Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * - Male Female Employment Status * - Full-Time Part-Time Self-Employed Unemployed Employer * Primary Care Provider * Emergency Contact * Relationship * Emergency Contact Phone * (###) ### #### May we discuss your medical condition and treatment plan with someone else, like a friend or family member? Yes No If yes, please give us the name of the person(s) that we are allowed to talk to: Primary Insurance Company (for prescriptions purposes) * Phone * (###) ### #### Group Number ID Number Policy Holder Name Policy Holder Date of Birth (mm/dd/yyyy) Policy Holder Security Number Relationship to the Insured Policy Holder Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you had any of the following symptoms? Select all that apply. Weight Loss Weight Gain Decreased Appetite Problems Falling Asleep Problems Staying Asleep Heart Palpitations High Blood Pressure Chest Pains Chest Tightness Shortness of Breath Frequent Headaches Motor Tics Verbal Tics Anxious Rigid / Inflexible Depression Paranoid Racing Thoughts Obsessive Compulsive Behavior Over Sensitive / Sensory Issues - Hates Tags - Loud Noises - Certain Food Textures Aggression Frequent Anger Substance Abuse None of the Above Medical Allergies Current Medications ADHD Medications taken in the past two years Family History. Select all that apply. Addiction / Substance Abuse Heart disease less than 50 Hypertension Headaches / Migraines Tics / Tourettes Depression Bipolar Disorder Obsessive Compulsive Disorder Anxiety Panic Attacks Schizophrenia / Psychosis ADHD Sleeping History. Select all that apply. Trouble falling asleep Trouble staying asleep Sleep walking Sleep talking Nightmares / Terrors Gone 24 hours without sleep Do you frequently sleep after work/school Do you frequently feel tired or fall asleep throughout the day Have you ever been formally diagnosed with ADHD? Yes No If yes - when were you diagnosed and by whom? Do you have documentation of previous testing? Yes No Are you currently under a provider's care for ADHD? Yes No Why are you changing ADHD providers? Number of children - 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+ What is your highest level of education? Are you currently in college/grad school? - Yes No What kind of work do you do? Do you exercise regularly? - Yes No How would you describe your general stress level? What is your driving history? Select all that apply. Violations Accidents License Suspended or Revoked How many caffeinated beverages do you consume per day? None 1 to 2 3 to 5 6 or more Do you use alcohol? - Yes No If yes - how often? Do you use tobacco or vape? - Yes No Do you use marijuana? - Yes No Have you used or are you currently using illicit drugs? - Yes No Do you participate in any type of rehab program or substance abuse counseling? - Yes No Have you had any legal issues? * - Yes No Did a friend or family member refer you to our clinic, if so what is their name? * Have you read the HIPAA Privacy Notice * Yes Thank you! HIPAA Privacy Notice Back to Patient Forms
