General Health Intake

Please take a moment to provide us with some information about your health history. For your convenience all forms can be easily completed online without the need to print or fax. Just remember to click “submit” at the bottom of the page and we will receive your information securely. If you have insurance and would like our office to check insurance availability please complete the “Insurance Eligibility” form on our website. If you would like to schedule an appointment you may do so by using the automated system on our website.
  • Month/Day/Year
  • Include name, address and/or phone number.
  • Please share your partner's name, their preferred pronouns and any other information you may think is relevant. This information may be important to a number of sensitive conversations, for example, for those seeking fertility support.
  • It really helps us to know how you found our office and we appreciate your help! Did you see an ad online or in print? Do you know which ad? Did you search on google? Were you referred by a Healthcare provider or family/friend? Did you get a mailing? Find us on Social Media? Did you see us on another website? Any information helps!
  • Acute History

    If you are having any issue, condition or concern that needs to be addressed right away.
  • Family History

  • Your Complete Health History

  • Please let us know how you identify & if you have preferred pronouns.
  • If you know any information about your own birth experience, please let us know. For example prolonged labor, forceps, etc. Additionally, if you would like to disclose the gender you were assigned at birth please share here.
  • How would you describe your emotional health?
  • Check any symptoms currently experienced or experienced in last 3 months.

    Check if you have had pain, numbness or weakness in the following
  • Reproductive Health Section 3

  • List results if you know them. Optimal to bring a copy with you to your appointment or you can have them faxed/emailed to our office.
  • Do you use contraceptives? If yes, please list all that apply. Condoms, Pill, IUD (copper or hormonal), Sponge, Spermacide, Cap, etcetera.