$9/unit BotoxMay only
Fort Wayne Direct Primary Care
New patient intake

New patient form.

Fill this out before your first visit. Five short steps — about 10 minutes. Your answers go directly to Dr. Aluri's office.

  1. 1Health & Wellness History
  2. 2Psychosocial Assessment
  3. 3Social History
  4. 4Medication History
  5. 5Mental Health

Patient information

This form collects the information Dr. Aluri needs for your first visit. Fields marked with an asterisk are required.

Basic information
Address
How did you hear about us?
Pharmacy
Primary care physician
Basic health history

Select N/Aif you don’t know the answer.

Has your doctor advised you to lose weight?
Do you feel more stressed than usual?
Are you on medication for anxiety or depression?
Do you have any dietary restrictions?
Are you currently breastfeeding?
Might you be pregnant?
Are you pregnant?
Family or personal history of thyroid cancer?
Family or personal history of any other cancers?
Any other symptoms associated with your chief complaint?
About your visit today
Past weight-loss programs
Weight Watchers
I have never tried to lose weight
Jenny Craig / Nutrisystem
South Beach / Atkins diet
Liquid diets
Keto diet
Weight-loss surgery
Medically supervised treatment
Phentermine
Other OTC or prescription medications for weight loss
Have you maintained loss for at least a year on any program?
Did you have weight problems in childhood?
Adult weight history
Step 1 of 5