Patient Health Questionnaire
Please provide accurate responses. All information is confidential and can only be viewed by the medical practitioner you speak with at Simply Medical Cards. Your information is protected by and subject to Federal HIPAA laws.
Required Notice: Please read our HIPAA Notice of Privacy Practices before completing this form. Federal law requires that this notice be made available to you.
Patient Information
Notice to patients in Iowa and Virginia only: We are required to provide a video call. Please indicate where you would like to receive a link to your video call.
Please log into the link five to ten minutes prior to your scheduled appointment time.
Qualifying Medical Condition
Medications & Allergies
Medical History (Diagnosed, Current or Previous)
Substance Use History
Please answer accurately. Information is for provider use only and does not affect your qualification to obtain the medical card.
Additional Information
