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Ascendant Telehealth

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Reason for care

Select date & time

1 Appointment info

Reason for care

3 Contact information

What is the reason for seeking care?

You will have space to explain more later on the form.

Anxiety Depression Cold/Flu Allergies Sinus Infection Conjunctivitis (Pink Eye) Ear infection Skin Infection Sore Throat Nail Infection Upper Respiratory Infection Urinary Tract Infections (UTI) STI (Screening/Treatment) HIV (Prep) Vaginal Infections (BV, Yeast Infections) Medical Weight Management Travel Medicine Back Pain (Musculoskeletal Pain) Neck Pain (Musculoskeletal Pain) Hypertension management (High Blood Pressure) Type 2 Diabetes management Smoking Cessation Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.