904-853-5867 904-853-5885 contact@biomentalclinic.com
Intake Virtual Appointment Referrals
BioMental Clinic

Patient Intake Form

Complete this form before your appointment so your provider can review recent symptoms, medications, and treatment updates.

Patient Details

Recent Changes and Follow-Up Questions

Use these questions to update our team before your appointment.

Have you had any medication changes in the last 1-2 weeks?
Have there been any changes to your sleep patterns?
Have you seen your Primary Care Provider (PCP) since your last appointment? (Routine PCP follow-up is required at least once per year.)
Have you had any lab work done since your last appointment? (Routine lab work is required at least once per year. Your provider may request lab work more often when clinically necessary.)
Have you noticed any improvements since starting treatment?
Have you experienced any side effects since starting treatment?
Have there been any changes regarding your health that Dr. Galliano or your provider should be notified of?
Do you have any specific concerns for your provider?

Patient Health Questionnaire (PHQ-9)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

PHQ-9 Score

Calculated automatically as you answer

0
If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

GAD-7 Score

Calculated automatically as you answer

0

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

This section only appears for patients with an OCD diagnosis and follows the structure of the existing intake questionnaire.

Do you have an OCD diagnosis?

This form will be submitted securely to our team for review.