Premise Health
Behavioral Health
Pre-Visit Form
Behavioral Health

Pre-Visit Form

A brief form to help your provider understand what has been happening before your appointment.

Your provider has asked you to complete this brief pre-visit form before your appointment. It should take about 5 to 7 minutes to complete.

The information you share helps your provider better understand what has been happening and allows more of your appointment to be spent discussing your concerns and goals.

There are no right or wrong answers. If you are unsure how to answer a question, it is okay to choose the closest options, leave items blank, or write "I'm not sure."

Behavioral Health Pre-Visit Form
Step 1 of 7

What brings you in today?

Select any options that fit. Use the optional text box if the choices do not fully capture your experience.

Select all that apply.

Select all that apply.

Optional.

How has this been affecting you?

Select any areas that have been affected.

5
Not muchVery much

A recent example

Think about one recent time when this was especially noticeable.

Select all that apply.

Select all that apply.

Select all that apply.

When this happens

These questions help your provider understand the part that feels most difficult.

Select all that apply.

Select all that apply.

Select all that apply.

Select all that apply.

Optional.

What changed?

Select anything that happened around the time these concerns began or became worse.

Select all that apply.

Select all that apply.

About you

A little context helps your provider understand what is typical for you.

Select all that apply.

Select all that apply.

Review and save

When you are finished, save this form as a PDF and upload it to your patient portal before your appointment.

Optional.

Provider Summary

Click any summary box to return to that section and edit before saving.

This summary is generated from selected responses. Complete responses appear in the form when saved as a PDF.

Save and upload your form

Please save a copy as a PDF and upload it to your My Premise Health account before your appointment.

Save as PDF.
Select the button below, then choose Save as PDF from your print options.
Open My Premise Health.
Go to your My Premise Health account or use the My Premise Health app.
Upload the PDF.
Send the saved PDF as an attachment before your appointment.