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Clinical Intake
Please complete your medical history so Dr. Sinai can provide the best possible care at your first visit.
What this form covers
This form takes about 15–20 minutes. Have your medication list and pharmacy information handy. If you're unsure about a question, do your best or leave it blank — we'll review everything together at your first visit.
Allergies & medications
Current prescriptions, supplements, and known allergies
Medical history
Past diagnoses, surgeries, and hospitalizations
Family history
Conditions in parents and siblings
Screening & wellness
Recent tests, PHQ-9 depression screening
Before you begin
Please complete this form in one sitting. You'll need about 15–20 minutes of uninterrupted time. Please have the following handy:
- Your current medication list (with dosages)
- Your pharmacy name & location
- List of allergies (medications, foods, other)
- Past surgeries & hospitalizations (year & reason)
- Family medical history (if known)
- A current email address (any provider)
Your privacy matters to us.To protect your personal health information, we intentionally don't store partial responses — so if you need to step away, please come back and start fresh. If you'd prefer a paper version, call us at (702) 749-8891.
New Patient Clinical Intake
Your privacy is protected.
This clinical intake form is hosted on Google Workspace under a HIPAA Business Associate Agreement. Your medical history is transmitted over an encrypted connection and stored in a HIPAA-compliant environment. See our Notice of Privacy Practices for details.