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?


Emergency


Insurance Information

Please also include a photo of your insurance card.

Attachments





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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