Medical Appointment Anxiety Intake Form
Help us understand your experience with anxiety related to your upcoming medical appointment. Your responses will assist us in making your visit as comfortable as possible.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How would you rate your current level of anxiety about your upcoming appointment?
*
No anxiety
1
2
3
4
5
6
7
8
9
Extreme anxiety
10
1 is No anxiety, 10 is Extreme anxiety
What are your main concerns or worries about this appointment?
*
Have you experienced anxiety before medical appointments in the past?
*
Yes
No
If yes, what strategies or techniques have helped you manage your anxiety?
Would you like to request any specific accommodations or support during your appointment?
Is there anything you would like your provider to know before your visit?
How would you prefer to be contacted regarding this appointment?
*
Email
Phone
Submit
Should be Empty: