New Patient Inquiry

Legal Name*

First Last

Date of Birth*

Address*

City State / Province / Region ZIP / Postal Code

Phone #*

Email*

I give permission to receive information from the office of Dr. Heithaus by email

Referred by

Please let us know if another provider or current patient referred you to our office

Have you been previously diagnosed with ADHD*

Year Diagnosed

Other Diagnosed Medical Conditions:

Have you taken medication for Anxiety?

Have you taken medication for Depression?

Have you taken medication for Panic Disorder?

Have you taken medication for Addiction?

Have you taken medication for Insomnia?

Have you taken medication for Sleep Apnea?

Have you taken medication for Hypertension?

Have you taken medication for Cardiac Abnormalities?

Have you taken medication for Hypo/Hyperthyroidism

ADHD Drug Shortage - Steps to take if your med is out of stock