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Name(Required)

First Middle Last Suffix

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Weight

Height

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Ethnicity(Required)

Select all that apply

White

Black or African American

Hispanic or Latino

American Indian or Alaska Native

Asian

Pacific Islander

Other

List of Medications

RX Name

Dosage

Pharmacy Name & Address

Pharmacy Phone #

Use the (+) sign to add multiple medications

Do you have any allergies?(Required)

Please list any known allergies:

Are you on Medicare?(Required)

What Medicare parts are you enrolled in?

Medicare Part A

Medicare Part B

Medicare Part C

Medicare Part D

Medicare Part E

Medicare Part F

Medicare Part G

I don’t know / Unsure

What is your Supplemental healthcare information?

Health Insurance Name(Required)

Medical/Policy Number(Required)

What is your current living situation?

Live at home / Assisted living / Independent living, etc.

Doctors and Specialists

Name

Provider Specialty

Phone #

Use the (+) sign to add multiple doctors or specialists

What types of things would you like your provider or specialists to help you with?

Do you have a Care Plan managed by your primary care doctor or specialists?(Required)

If yes, do you have a copy?

Caregiver(s)

Name

Phone #

Use the (+) sign to add multiple caregivers

Would your Caregiver or family member like to participate in the program?

Caregiver or family members' preferred method of contact:

Have you had any recent surgeries?

If yes, please explain

Have you had any recent visits to the hospital or skilled nursing facility?

If yes, please explain:

Are you seeing a mental health professional?

If yes, please list:

Name

Phone #

Is there anyone else making decisions on your behalf?

If yes, please list:

Name

Relationship

Phone #

Do you have a DNR?

Do you have a will in place?

Are you familiar on how to use email?

Do you know or understand how to use most web or mobile applications?

Do you have Wi-fi?

Is there someone that helps with using Wi-Fi or other technical assistance?

If so, please list their name(s) and relationship to you:

Name

Relationship

Phone

Use the (+) to add multiple lines

Is there a caregiver that would like to participate in the Chronic Care Management program?

Non- Face to Face encounters

If yes, please list their name, relationship and contact information:

Name

Relationship

Phone #

Use the (+) to add more than one caregiver

Please tell us what your health goals are in the next year:

What chronic conditions are most troubling to you?

What is your expected outcome with our Chronic Care Management program?

Do you drink alcohol?

Do you use recreational drugs?

Do you smoke cigarettes?

Please list your medical conditions below:

Use the (+) to add multiple lines

Do you have any pre-existing medical conditions?

Is there a history of serious illnesses in your family?

If yes, please specify:

Date of last Blood Pressure check

MM slash DD slash YYYY

Results of last Blood Pressure check:

What is your COVID-19 vaccination status?

One dose

Two doses

Booster

Unvaccinated

Other

Consent(Required)

I agree to participate in the Chronic Care Management program

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Digital Patient Enrollment

Improve Patient Outcomes and Increase Continuity of Care