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(678) 344-8268

NEW PATIENT INTAKE

PATIENT INFORMATION

Gender

Male

Female

Appointment Reminders:

Text Message

SOCIAL HISTORY

Employment Status

Full-Time

Part-Time

Unemployed

Retired

Disabled

CURRENT BEHAVIORAL HEALTH STATUS

Are you experiencing any of the following?

Depression

Anxiety

Memory Problems

Anger Outbursts

Paranoia

Hallucinations

Mood Swings

Panic Attacks

Sleeping Problems

Manic Behaviors

PTSD

Suicidal/Homicidal Thoughts

Difficulty Focusing/Concentrating

FAMILY HISTORY

MEDICAL HISTORY

Do you have/had any of the conditions listed below:

High Blood Pressure

Diabetes

Thyroid Problems

Cancer

High Cholesterol

Asthma or COPD

Migraines

Anemia

Heart Disease

Fibromyalgia

Stroke

Seizures

Sleep Apnea

MEDICATIONS/PHARMACY INFO

INSURANCE INFORMATION

Select an option

Insurance

Self-Pay

ALLERGIES

OTHER HEALTH INFO

By checking this box I acknowledge that I am the patient or authorized guardian for the person listed and have filled out the information to the best of my knowledge. I accept that this information will be sent electronically to Life Healing Center, PC for input into their Electronic Medical Record system.

by typing your name above, you are signing this document electronically.

Thanks for submitting! Your information has been sent to Life Healing Center, PC. Please call us at 678-344-8268 with any questions.

Please note you will still need to sign treatment consent and office policy acknowledgements when you arrive to the office. These forms are available for review under our Patient Info tab on this site.

You will also need to provide a copy of your ID and insurance card at time of service along with any copays that are due.

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