Unity Point Health Form


First Name
Last Name
Birthday
Address
Email
Gender female
male
other/nonbinary

Reason For Visit

Relationship Status
Pronouns
Drug Use
yes
no
sometimes
Have you been tested for HIV/AIDS in the last 6 months? yes
no
I have never been tested
Are you currently sexually active? yes
no
Have you ever experienced gender dysphoria?
yes
no
sometimes
I dont know what this is
How many times a week do you have an alcoholic beverage?
Do you have any allergies? yes
no
If so please list here

Have you left the country in the last 6 months? yes
no
How many days a week would you say you are active for more than 45min?
Do you have a history of skin cancer in your family? yes
no
Do you have a history of high blood pressure in your family? yes
no
Do you have a history of diabetes in your family? yes
no
Does your family have a history of alcoholism? yes
no
Does anyone in your family suffer from depression or other mental illness? yes
no
Have you gotten a tattoo in the last 3 months? yes
no
Was it done at a certified tattoo shop? yes
no
On average, how many hours of sleep do you get a night?
On average, how many servings of vegetables do you get a in a single day?
On average, how many servings of fruit do you get a in a single day?
On average, how many meals do you get a in a single day?
Have you gotten a physical in the last year? yes
no
Please check all that apply:
I have graduated from high school
I have graduated from college
I am currently enrolled in high school
I am currently enrolled in a college
I have a graduate/masters degree
I am currently enrolled in masters/graduate program
How many times a day do you brush your teeth?
How many times a day do you floss your teeth?
Do you wear a seatbelt while driving/riding in a car? yes
no
Do you feel safe in your current living enviornment? yes
no
Do you or someone you live with own a gun? yes
no
If you answered yes to the last question, is the gun/guns kept in a locked safe? yes
no
Are you vegan? yes
no
Please enter your current weight
Please enter your current height
Are you currently employed? yes
no