Intake General History – Northwestern Access

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Provider ID (Hidden)

Are you at least 18 years old and live in Illinois?(Required)

Yes

No

We're sorry, but you're not a good fit for our treatment.

State laws require that you live in Illinois and are at least 18 years old to receive treatment from Dr. Vinay's

What's your date of birth?(Required)

MM slash DD slash YYYY

What was your gender at birth?

Female

Male

Do you have any of the following apply to you?

Do you have any health conditions?(Required)

Do you have any health conditions?

Yes

No

Please list your health conditions

Have you had surgery in the past?(Required)

Have you had surgery in the past?

Yes

No

Please list your past surgeries

Are you taking any medications(Required)

Are you taking any medications

Yes

No

Please list your medications

Are you allergic to any medications?(Required)

Are you allergic to any medications?

Yes

No

Please list your allergies

Congrats! You're eligible for treatment.

Let's get those locks back.