Primary Care Questionnaire Once this questionnaire has been reviewed, we will contact you regarding establishing care. Primary Care Questionnaire Name: Date of Birth Mailing Address Email Phone (appropriate for confidential messages) Do you live in Oregon? Yes No Do you have medical insurance? Yes No If insured, who is your provider and what type of plan do you have? If uninsured, will it be possible for you to pay at time of service? Yes No How were you referred to this office? Please list your main health concerns: Do you have an urgent need to be seen? Yes No If yes, what is the nature of your concern? Do you have a current primary care provider? Yes No If yes, who? Have you seen any specialists in the past two years? Yes No If yes, please list: Are you currently taking any prescription medications? Yes No If yes, please list: Are you interested in reducing or discontinuing prescription medication use? Yes No Are you interested in lifestyle, diet and nutritional intake improvement? Yes No What are the best days and times for you to schedule appointments? Submit Δ
