Patient Information

Relationship Status:

Barriers to Receiving Care:

Currently Pregnant?

Currently Employed?

Difficulty with the Following?

Preference for Method of Learning:

Tobacco Use:

If Yes, Interest in Quitting?

Alcohol Use:

Recreational Drug Use:

If Yes, Interest in Quitting?

How Would You Rate Your Overall Health?


Insurance Information

Please also include a photo of your insurance card.


Additional Information

Number of Pregnancies:

Pregnancy History (including Year(s), Gestational Age(s) at Delivery, Mode(s) of Delivery, Gender(s), Birthweight(s), Any Pregnancy Complications)

If have a telehealth appointment and would like another person to join from a separate location, please provide the name and email address for this person for receipt of the telehealth link:

Patient or Guardian (where applicable) Signature:

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