Never Have I Ever Eviscerated Someone With the Surgical Precision Of a New Patient Intake Form
Please arrive at least 15 minutes before your appointment and bring something to do with your hands so you don’t just sit there looking so goddamn vulnerable.
Your appointment is confirmed. Please take 45 minutes to complete this brief questionnaire. Additionally, if this is your first appointment with EYES EYES EYES, please arrive at least 15 minutes before your appointment and bring something to do with your hands so you don’t just sit there looking so goddamn vulnerable. It bums people out.
PATIENT INFORMATION
Patient name:
DOB:
Social Security Number (Yep, we need it! Even for this!):
*Patient hesitates*
*Demonic voice whispers, “Do it.”*
*Patient relents, mutters, “Nothing matters, anyways.”*
MARITAL STATUS
We don’t really need to know. We just want to see if you’ll tell us.
__ Single (Still)
__ Married
__ Widowed
__ Swindled
EMERGENCY CONTACT
It’s in case you die on our watch. There. We said it.
Name:
Phone:
Relationship to patient:
__ Relative
__ Spouse/Partner
__ Roommate*
*IF you selected “roommate” AND you are over 30 years of age, please specify a.) the point at which you realized all your plans had gone horribly, terribly wrong, and b.) your mom’s cell # even though she’s 7+ hours away and sometimes leaves her phone at Barnes & Noble.
FAMILY HISTORY
Time to sing, snitch.
Has anyone in your family suffered from:
__ Asthma
__ Addiction
__ Cancer
__ Glaucoma
__ Heart disease
__ Being ugly
If you checked any of the above boxes, please list the person’s relation to you (e.g., Mom, Dad, Sister, Long-Dead Paternal Grandmother Who Doesn’t Deserve To Be Dragged Into This, etc.) and the worst thing they ever did. First and last names, please!
PERSONAL HISTORY
A few simple questions that will haunt your medical chart for the rest of your days.
Check all that have ever applied—EVER. If you check more than four, calm down. You’re not that special.
SOCIAL HABITS
Are you cool? Or do you, like, have a problem?
TOBACCO USE (circle one): Y / N
If YES, type:
__ Cigarettes
__ Vape
__ Dip lol
Frequency:
__ Daily
__ <5x/week
__ Only when I’m drunk so it doesn’t count
ALCOHOL USE (circle one): Y / N
If YES, type:
__ Beer
__ Wine
__ Liquor
Frequency:
__ 1-3 drinks/wk
__ 4-6 drinks/wk
__ Like I’m a crew member on Below Deck
RECREATIONAL DRUG USE (circle one): Y / N
If YES, type:
__ Marijuana
__ Loose purse pills
__ Cold brew