East Tennessee Psychiatric Services New Patient Intake
East Tennessee Psychiatric Services New Patient Intake Today's Date: [date name="Date"] Reason for visit:[textarea name="presenting problem"] Identifying Data First Name:[text name="Patient's name" size="10"] Middle Initial:[text name="Patient's name" size="5"]Last Name:[text name="Patient's name" size="10"] Date of Birth:[date name="Date of birth"] Social Security Number:[text name="SSN" size="20"] Primary Phone Number:[text name="Phone" size="30"] What type of phone is this:[select name="phone" value="Home|Cell|Work|Other"] Do you give East TN Psych. Services permission to call, text, and leave voicemail at this number? [select name="phone" value="Yes|No"] Primary Email:[text name="email" size="50"] Do you give East TN Psych. Services permission to communicate with you via this email address? (email is NOT considered a secure form of communication. Sensitive data will never be sent via email [select name="email" value="Yes|No"] Emergency Contact Name:[text name="EC " size="20"] Phone:[text name="EC " size="20"] Relationship to you:[text name="EC " size="20"] Sex:[select name="Sex" value="|Female|Male|Other|Prefer not to say"] Gender Identity:[select name="GI" value="|Male|Female|Transgender|Non-Binary|Intersex|Other|Prefer not to say"] Marital Status:[select name="Marital Status" value="|Single|Married|Long-term partner|Separated|Divorced|Widowed|Other"] Street Address: [text name="address" size="30"] City:[text name="address" size=25"] State:[select name="State" value="AL|AK|AZ|AR|CA|CO|CT|D.C.|DE|FL|GA|HI|ID|IL|IN|IA|KS|KY|LA|ME|MD|MD|MA|MI|MN|MS|MO|MT|NE|NV|NH|NJ|NM|NY|NC|ND|OH|OK|OR|PA|RI|SC|SD|TN|TX|UT|VT|VA|WA|WV|WI|WY|"] Zip:[text name="address" size="10"] Who lives in the home with you? [textarea name="Home "] Employment Status:[select name="job" value="Full-time|Part-time|Self-employed|Student|Retired|Disabled|Unemployed"]Occupation:[text name="job" size="20"]Employer:[text name="job" size="20"] Highest level of Education:[text name="job" size="20"] Religious or Spiritual Preferences:[text name="job" size="20"] Are you affiliated with a religious or spiritual organization? If so, please Indicate where:[text name="job" size="50"] Psychiatric History Have you ever been hospitalized for a psychiatric reason? [radio name="Have you ever been hospitalized for a psychiatric reason?" value="No|Yes"] If yes, please list the approximate date:[text name="psych" size="20"] If you answered "yes", please indicate how many times you have been psychiatrically hospitalized:[text name="psych" size="20"] Please indicate the name or locations of the facility(s) you have been hospitalized:[text name="psych" size="20"] How old were you when you were first hospitalized?[text name="psych" size="10"] Please list the reason(s) for your hospitalization(s):[text name="psych" size="20"] Are you currently receiving outpatient psychiatric treatment? [select name="psych" value="Yes|No"] Location of current outpatient psychiatric treatment: [text name="psych" size="20"] Name of current mental health provider: [text name="psych" size="20"] Are you in therapy? [select name="psych" value="Yes|No"] Name of current therapist: [text name="psych" size="20"] If you are not currently under the care of a mental health professional, have you ever been in the past? [select name="psych" value="Yes|No"] If so, where? [text name="psych" size="20"] Are you currently prescribed any psychiatric medications? [select name="psych" value="Yes|No"] If so, please list any psychiatric medications you are currently taking: [textarea name="Meds"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.34, 44 form elements, 269 boilerplate words, 26 text boxes, 3 text areas, 2 dates, 1 radio buttons, 12 drop downs, 44 total clicks
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