Step 2 of 2
Clinical Intake
Please complete your medical history so Dr. Sinai can provide the best possible care at your first visit.
Existing Dr. Sinai patients - you can skip this form
If you are transferring from Dr. Sinai's previous practice (IMS), your medical records are already on file. You only need to complete the Step 1 Membership Enrollment.
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.