Client First Name (required)
Client Last Name (required)
Phone Number (required)
Your Email (required)
Date of Birth (required)
Name of Emergency Contact Person (required)
Emergency Contact Phone Number(required)
If you are expecting to receive medication, please tell us your preferred pharmacy. Be more specific (for example, CVS on Franklin in Minneapolis):
Your Housing Status Personal ResidencyGroup HomeShelterFoster Home
Marital Status(required) SingleMarriedDivorcedSeparated
Level Of Education Completed(required) High school diploma or GEDSome collegeAssociates or VocationalBachelor's degreeMaster's degreePhD
Are you Veteran YesNo
If yes, Are you currently active duty YesNo
Race WhiteAfrican AmericanAsianHispanic/LatinoAmerican IndianNative HawaiianDecline to answer
Country of Origin United StatesOther
Primary language EnglishOther
Have you ever been involved in any legal issues NoYes
How did you hear us? EmployerFriendFamily memberInternet
Who referred you to us?
Do you have any cultural considerations you would like your provider to ask about? NoYes
Do you have any religious considerations you would like your provider to ask about? NoYes
Do you have any concerns about your housing or financial situation? NoYes
Weight
Height
Date of Last Exam (required)
What is/are your reason(s) for seeking services at Priomh?
Cardiovascular Coronary artery diseaseHeart surgeryHypertensionAbnormal blood pressureHigh cholesterolFainting spells
Respiratory EmphysemaAsthmaSleep apnea
Endocrine Thyroid problemsDiabetes
General Currently/possibly pregnantCurrently breastfeedingWeight changes
Genitourinary HIV/AIDS/ARCUrinary incontinenceKidney/bladder problemsSexually transmitted disease
Blood/lymph CirrhosisAnemiaHepatitis
Musculoskeletal Broken bone(s)FibromyalgiaChronic fatigue syndromeArthritisRheumatic disease
Neurological HeadachesStrokeHead injuryMemory lossEpilepsy or seizures
Skin Skin disordersTubercolosisAcne
Allergies/Immune ImmunosuppressedHayfever
Gastrointestinal UlcersAbdominal painNauseaDiarrheaConstipation
Auditory/Vision Visual problems other than corrective lensesHearing impaired
Have you ever been hospitalized including psychiatric NoYes
If yes, please explain:
Have you had or do you currently have cancer? NoYes
Have you had any surgeries? NoYes
Please list any current prescription medications, including dosage:
Please list any food or medication allergies:
