Arizona

Pre-Assessment

Questionnaire

All information submitted is confidential and secured via HIPAA compliant encryption. Please answer all questions completely and truthfully. We wish to allocate and plan for resources most suitable for your needs and avoid downstream delays or disruption in your care. Please reference your prior records, medications, and our practice website for more information. Before we establish care, we ask that you complete a Pre-Assessment Questionnaire (PAQ)/Prospective Patient Questionnaire that will guide our administrative team to determine your level of care and start planning your care. All your information will remain private and will be used solely for timely onboarding. The form should take between 10-20 minutes to fill out and autosaves your progress.