Pre-Screening Questionnaire

This questionnaire helps determine whether Direct Primary Care services are appropriate, safe, and within the scope of care offered by our practice.

Questions? Please call us at (440) 253-0868.

Name
Preferred method of contact
Emergency contact name
Briefly describe your main concern or reason for seeking care.
How long have you experienced this concern?
Have you received care for this condition before?
Medical history
Please check all that apply
If any are checked, please explain.
List all current medications, including OTC and supplements.
Do you have any medication or food allergies?
Are you currently under the care of another healthcare provider?
Have you been hospitalized or had surgery in the past 12 months?
Do you currently have any unresolved or worsening symptoms?
Are you currently experiencing any of the following?
If you checked any of the above, immediate or emergency care may be required and Direct Patient Care (DPC) may not be appropriate at this time.
Which type(s) of care are you seeking?
Do you understand that Direct Patient Care (DPC) does not replace emergency services and may not include specialty or hospital-based care?
Do you understand that Direct Patient Care (DPC) services may be self-pay and not billed to insurance?
Are you willing to discuss fees prior to receiving care?
Consent and acknowledgment
By checking “I Agree” above, I certify that the information provided is accurate and complete to the best of my knowledge. I understand this questionnaire is used solely to determine eligibility for Direct Patient Care (DPC) and does not establish a provider-patient relationship.