New patient intake

New Patient Intake Form

Please complete this form before your first visit, and bring all medication and supplement bottles with you. Your answers help Dr. Buddhavarapu build an individual plan and decide which approaches — and which practitioners — fit your situation.

1Patient information

Full name Date of birth Phone Email Address Emergency contact Their phone Referred by Primary care physician

2Reason for visit and goals

What brings you in, and for how long has it been a problem? What would you like to be different six months from now?

3Medical history

Current medical conditions Surgeries and hospitalizations, with approximate years Allergies (drugs, foods, other)

4Medications and supplements

Prescription and over-the-counter medications List each on its own line — name, dose, and how often. Vitamins, herbs, and supplements List each on its own line — name, dose, and how often.

6Mental health

Have you been diagnosed with or treated for any of the following? (check all that apply) DepressionAnxietyPTSDBipolar disorderPsychosis or schizophrenia

Current mental health treatment or provider

8Substance use

Tobacco Alcohol (how often) Caffeine per day

Cannabis (current use and form) Other

9Lifestyle

Typical diet

Sleep — hours per night Sleep quality Exercise (type, how often)

Stress level (0–10) Main sources of stress

11Family history

Major conditions in parents or siblings

12Acknowledgments

I understand that this practice does not participate in insurance plans and that payment is due directly. Documentation for out-of-network claims is available on request.

I understand that my plan may include referral to other practitioners with whom Dr. Buddhavarapu works, and that he remains responsible for coordinating my overall care.

Preferred way to reach me CallTextEmail

Signature (type your full name) Typing your name here serves as your signature. Date