AutoPsych Nonsubscriber Med-Check

AutoPsych Med-Check

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Please Verify Your Information
Please Verify Your Name*

First NameLast Name
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Date
Please Verify Your Phone Number*
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Please verify your preferred email address*
example@example.com
Important Clinical Information

This is required for us to safely monitor your care response.
Reason for your visit:*

Regular check inI would like to adjust/change my medsOther
Any problems today?*

All goodNot so good, I need to speak with someone right awayOther
Are we making any progress?*

Lots of progressSome progressAbout the sameWorseOther
Any medication side effects?*

None at allYes, but they're mild and tolerable and I'm not worriedYes, they're severe, I'm worried, and I need to speak with a provider right away
Blood pressure*

NormalAbnormal
Blood Pressure and Heart Rate Measurement Instruction and Guidelines
Resting heart rate*

NormalAbnormal
Current weight (lbs)*
Height (in)*
Let's Check on a Few More Important Things
Please select any that apply to you:*

I feel fineI am having trouble focusing and getting things doneI am having difficulty staying calmI am not sleeping wellOther
Anxiety Screener *

1

2

3

4

5

1 is Not worried at all, 5 is More worried than ever before
Depression Screener *

1

2

3

4

5

1 is Not sad at all, 5 is More sad than ever before
ADHD Screener*

1

2

3

4

5

1 is Laser focused, 5 is Can't focus at all
How would you like to check in next time?*

AutoPsych(like this)Live online visitOther
Please verify your preferred Pharmacy*

Same as last timeOther
Freestyle. Tell us anything, always private, always secure.
May we contact you using email and/or text to communicate your care plans and clinical information with you?*

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AutoPsych ConsultationConsultation to continue regular care. Service includes care plan review and care coordination, including medication management, and referral for professional in-person consultation when necessary. For use with established patients only.

$249.99

Total

$0.00

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AutoPsych Med-Check

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Important Clinical Information

Let's Check on a Few More Important Things

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