Psych Questionnaire

Basic Info

Please Fill Out As Accurate As Possible

Questionnaire (20 Questions)

Please take a few moments to fill out the personal health profile below, making sure to answer all of the questions to the best of your knowledge. The following questions are needed for your healthcare provider to accurately review your current health status.

Insurance

(Optional) Please upload your Insurance Card and State ID or Drivers License

HIPAA Privacy Policy

HIPAA Privacy Policy

Payment

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Basic Demographics

Name

State Acquiring For Services

Phone Number

Email

Gender

Gender

Question 1

Have you now or ever in the past been diagnosed with any high blood pressure problems or related disorders?

If Yes, please take a minute to give us some detail

Question 2

Have you now or ever in the past been diagnosed with any skin disorder or related problems?

If Yes, please take a minute to give us some detail

Question 3

Have you now or ever in the past been diagnosed with any ear, nose, or throat disorder or problems?

If Yes, please take a minute to give us some detail

Question 4

Have you now or ever in the past been diagnosed with any breathing problems, lung problems, asthma or any related respiratory problems?

If Yes, please take a minute to give us some detail

Question 5

Have you now or ever in the past been diagnosed with any heart, blood vessels or related circulation problems?

If Yes, please take a minute to give us some detail

Question 6

Have you now or ever in the past been diagnosed with any benign or malignant tumors/cysts or any history of cancer of any kind?

If Yes, please take a minute to give us some detail

Question 7

Have you now or ever in the past been diagnosed with any urinary tract, urethra, prostate, kidney or bladder problems of any kind?

If Yes, please take a minute to give us some detail

Question 8

Have you now or ever in the past been diagnosed with any disorder of the blood or related problems?

If Yes, please take a minute to give us some detail

Question 9

Have you now or ever in the past been diagnosed with any difficulty with hormones or hormone levels or any related problems?

If Yes, please take a minute to give us some detail

Question 10

Have you now or ever in the past been diagnosed with any bone, joint or muscle disorders of any kind?

If Yes, please take a minute to give us some detail

Question 11

Have you now or ever in the past been diagnosed with any cancer?

If Yes, please take a minute to give us some detail

Question 12

Have you now or ever in the past been diagnosed with any infectious diseases of any kind, including the flu?

If Yes, please take a minute to give us some detail

Question 13

Have you now or ever in the past been diagnosed with any nerve problem or related neurological disorder?

If Yes, please take a minute to give us some detail

Question 14

Have you now or ever in the past been diagnosed with any sexually transmitted disease of any kind?

If Yes, please take a minute to give us some detail

Question 15

Do you currently have any other medical conditions that are not answered by the above questions?

If Yes, please take a minute to give us some detail

Question 16

For Females. – Any history of obstetric or gynecological infections, growths, tumors, cysts and related OB/GYN problems?

If Yes, please take a minute to give us some detail

Question 17

Have you been told that you have thyroid, pituitary or any other endocrine related problems?

If Yes, please take a minute to give us some detail

Question 18

Do you currently take any medication prescribed by a physician, physician assistant or a nurse practitioner? If yes, please list the medications you are taking as best as you can.

Please list all of the medications you are taking as best as you can

What health problem or problems are you interested in having evaluated today with your ClickAClinic.com Health Care Provider?

Please tell us your interest in todays services, so we may match you with the best provider

Insurance Information

Please Select Which Type Of Insurance You Have

Upload A Copy of Your Inusrance Card and Drivers License or State ID: (Image Will Suffice)

HIPAA Privacy Policy

I have read our HIPAA Privacy Policy HIPAA PRIVACY POLICY CLICKACLINIC.COM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. A. PURPOSE OF THIS NOTICE CLICKACLINIC.COM, INC. (“CAC”) is committed to preserving the privacy of your health information. In fact, we are required by law to do so for any health information created or received by us. CAC is required to provide this Notice of Privacy Practices (“Notice”) to you. The Notice tells you how we can and cannot use and disclose the health information that you have given to us or that we have learned about you when you were a patient in our Online Telemedicine system. It also tells you about your rights and our legal duties concerning your health information. CAC is required to abide by this Notice and any future changes to the Notice that we are required or authorized by law to make at all CAC locations, including any medical facilities open to the public that CAC may operate both in Florida and in other states, any primary care and specialty clinics; psychiatric medical facilities or facilities offering psychological counseling services, and community service and outreach programs. This Notice applies to the practices of: • All CAC employees, volunteers, service providers, including clinicians, who have access to health information. • Any health care professional authorized to enter information into your CAC health record. • Any non-CAC clinicians who might otherwise have access to your health information created or kept by CAC, as a result of, for example, their call coverage for CAC, or CAC customer facilities and their employed physicians and clinicians. For the rest of this Notice, “CAC,” we” and “us” will refer to all services, service areas, and workers of CAC. When we use the words “your health information,” we mean any information that you have given us about you and your health, as well as information that we have received while we have taken care of you (including health information provided to CAC by those outside of CAC). You have given us permission to send you SMS and email messages and notifications without restriction. We will have a copy of the current Notice with an effective date in clinical locations and on our website at HIPAA Privacy Policy

Do you consent to have your New Patient information securely transmitted and stored with Specialty Natural Medicine and our HIPPA compliant technology vendors?

Your electronic signature below indicates your acceptance of the following terms. To complete the electronic signature, please type your name in the field below. I understand that I am giving ClickAClinic.com permission to perform a psychiatric evaluation. I understand that my Insurance Company may or may not pay for these charges, and I agree to be responsible for all charges pertaining to my care. PLEASE SIGN BELOW

1. Please click PAY NOW

2. (Payment ID is ClickAClinic)

3. The price for a Virtual PSYCHIATRIC Consult is $150.00