Tao Vitality New Patient Intake Form

New Patient Intake Form

This is a confidential record of your medical history and will be kept in this office. Information contained in it will not be released to any person unless authorized by you.
Date
00/00/0000
Full Name: First Middle Last
Date of Birth
00/00/0000
Address
City
State
Zip Code
E-mail
example@example.com
Home Phone Number
Home PhoneFormat: (000) 000-0000.
Work Phone Number
Work PhoneFormat: (000) 000-0000.
Mobile Phone Number
Mobile PhoneFormat: (000) 000-0000.
Gender
Employed By/Occupation
Marital Status
Number of Children
What contact number do you prefer we use?
May we leave a message?
Emergency Contact/Phone Number/Relationship
Name of Medical Doctor
Phone Number
How did you hear about us?

Other
Insurance (Primary)
ID#
Please upload a Photo ID or Driver's License

Cancelof

Health Concerns
What are your main health concerns in order of importance to you?
What forms of treatment have you used in the past to treat this condition?
Vitamins and Supplements
Please list all vitamin/mineral/herbal supplements you are currently taking: Supplement (Including Brand) Dosage/ When did you begin this supplement?
Medications
Please list all prescription and non-prescription medications you are currently taking: Medication/ Dosage/When did you begin this medication?
Please list all prescription medications you have taken in the past for longer than six months. Indicate how long you took each medication.

Family History
Next to each individual listed below, please put an “L” for living or “D” for deceased, as well as present age or age at the time of death. Please indicate if the family member suffered from any diseases such as cancer, high blood pressure, heart attack, stroke, diabetes, skin disorders or other. If unknown, write "Unknown"
Mother L/D-Age-Diseases Suffered-Cause of Death
Father L/D-Age-Diseases Suffered-Cause of Death
Maternal Grandmother L/D-Age-Diseases Suffered-Cause of Death
Maternal Grandfather L/D-Age-Diseases Suffered-Cause of Death
Paternal Grandmother L/D-Age-Diseases Suffered-Cause of Death
Paternal Grandfather L/D-Age-Diseases Suffered-Cause of Death
Sisters L/D-Age-Diseases Suffered-Cause of Death
Brothers L/D-Age-Diseases Suffered-Cause of Death
Maternal Aunts L/D-Age-Diseases Suffered-Cause of Death
Paternal Aunts L/D-Age-Diseases Suffered-Cause of Death
Maternal Uncles L/D-Age-Diseases Suffered-Cause of Death
Paternal Uncles L/D-Age-Diseases Suffered-Cause of Death

New Patient Intake Form