• New Patient Paperwork

    Note: this entire form must be completed in one sitting. Please allow yourself at least 30 minutes to complete.
  • What type of service are you interested in scheduling?*
  • Patient Gender*
  • Format: (000) 000-0000.
  • Is the patient 19 years of age or older?*
  • Do you have a legal guardian or power of attorney?*
  • Legal guardian/Power of Attorney:*
  • Were you referred here?*
  • Would you be interested in seeing a Behavioral Health provider at Alivation Health?*
  • Have you seen a Psychiatrist, Therapist, or Counselor in the past?*
  • Provider information *
  • Would you like us to send or receive any information to/from the above provider?*

  • **After you complete this form, please return to the Patient Information page to complete a Release of Information form.

  • Have you seen a Primary Care Provider before?*

  • The date of my last physical was: (MM/YYYY)*.

  • Provider information *
  • Would you like us to send or receive any information to/from your Primary Care Provider?*

  • **After you complete this form, please return to the Patient Information page to complete a Release of Information form.

  • Would you be interested in using Alivation Pharmacy for your medications?*
  • Would you like to have your other providers' scripts sent to Alivation Pharmacy?*
  • Do you have any siblings?*
  • Sibling's information*
  • Are you currently married?*
  • Were you previously married?*
  • Select one:*
  • Do you have any children?*
  • Child's name*
  • Any complications during this child's pregnancy (bleeding, infection, toxemia) ?*
  • Any complications during this child's labor (breach, prolonged, slow heart rate in baby)?*
  • Any problems during this child's delivery (c-section, forceps, heavy bleeding, premature, late)?*
  • Any problems during this child's hospital stay(yellow jaundice, trouble with formula, infections)?*
  • Has Child Protective Services (CPS) been involved?*
  • Do you have a Case/Social worker?*
  • Does anybody else live in your household?*
  • Please list the individual(s) who live with you:*
  • Are you currently in school?*
  • Are you employed?*
  • Select one*
  • Are you currently, or have you previously been, on disability?*
  • Do you have, or have you had, any legal offenses or charges?*
  • Do you have a religious or spiritual preference?*
  • Have you ever had any head/brain trauma, concussion, or hit your head and felt foggy, lightheaded, or dizzy?*
  • Did you ever lose consciousness?*
  • Did you receive treatment for this?*
  • Have you received a tetanus shot before?*
  • When was the last date it was received?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a pacemaker?*
  • Do you have metal in your head?*
  • Do you currently drink caffeinated beverages?*
  • Are you allergic to any medications, foods, or have any environmental allergies?*
  • Please list allergies (medication/food/seasonal/other)*
  • Do you have a history of drinking alcohol?*
  • Please fill out history of drinking alcohol. Types of alcohol include, but are not limited to: wine, beer, liquor, etc. You do not need to be specific with the brand or sub-class of alcohol.*
  • Do you currently or have you used illicit drugs?*
  • Please fill out illicit drugs*
  • Do you currently or have you smoked cigarettes or used any other tobacco products including vaping?*
  • Please list tobacco products below:*
  • Have you ever been the victim of physical abuse?*
  • Have you ever been the victim of emotional abuse?*
  • Have you ever been the victim of sexual abuse?*

  • Please select the option that best describes you

  • Meals*
  • Exercise*
  • Seat belts*
  • Do you have an advance directive?*
  • Has a copy been provided for our records?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Please mark all the symptoms that apply:

  • General*
    Rows
  • Head*
    Rows
  • Gastrointestinal*
    Rows
  • Urinary*
    Rows
  • Skin*
    Rows
  • Bone/ Joints/Muscles*
    Rows
  • Psychological*
    Rows
  • Neurological*
    Rows
  • Lungs*
    Rows
  • Heart*
    Rows
  • Men*
    Rows
  • Women *
    Rows
  • Women fill in the blank*
    Rows
  • Are you currently pregnant?*
  • Would you like us to send or receive any information to your specialist provider?

  • **After you complete this form, please return to the Patient Information page to complete a Release of Information form.

  • Are you currently breastfeeding?*
  • Have you seen a specialist?*
  • Would you like us to send or receive any information to your specialist provider(s)?

  • **Please fill out a Release of Information form in order for us to coordinate care.

  • Do you currently use a glucometer or other medical equipment?*
  • Do you feel well?*
  • Do you have ANY blood relative(s) with physical, mental health, or substance abuse history? Including but not limited to: alcoholism, arthritis, asthma, bleeds easily, cancer, diabetes, epilepsy, heart disease, high blood pressure, high cholesterol, kidney disease, mental illness, migraine, stroke, thyroid disease.*
  • Please list ALL blood relatives with a physical, mental health, or substance abuse history: *
  • Do you had ANY previous surgeries, hospitalizations, or other significant in-patient healthcare events?*
  • Please list OR upload a file. Uploading files is preferable for accuracy. Please list ALL previous surgeries, hospitalizations, or other significant in-patient healthcare events:
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have any CURRENT or PAST chronic illnesses?*
  • Please list ALL your CURRENT or PAST chronic illnesses: *
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you CURRENTLY take any medication(s)? Include prescribed, over-the-counter, vitamins, drops, and topicals.*
  • Please list ALL your CURRENT medications, dosages, and times taken each day: *
  • Have you PREVIOUSLY taken any medications? Include prescribed, over-the-counter, vitamins, drops, and topicals.*
  • Please list ALL your PAST medications, dosages, and times taken each day. *
  • Date signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Note: If submit button is not working, required information is not filled out. 

    Please scroll up to double check your information. 

  • 8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

    Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

    Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410

  • Should be Empty: