NEW PATIENT INTAKE FORM - Chicago/South Loop, IL

NEW PATIENT INTAKE
Name:*
Date*

MonthDayYear
Email address:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Phone (work)
Phone # (other)
Date of Birth:

MonthDayYear
Gender:
SS#:
SingleMarriedDivorcedWidowedSeparatedMinor
Occupation:
Employer:
Employer Address:
Phone:
Emergency contact:
Relation:
Phone:
Phone (work)
Phone (other)
Please list any additional health complaints:
Please list any surgeries (with dates)
Please list any medical conditions (past & present)
Family History: Please specify members of your family including extended family who have these illnesses.
Cancer:
Hypothyroidism:
Heart Disease:
High Blood Pressure:
Diabetes:
Obesity:
Current Medications/Prescriptions and Non-Prescriptions

Rows	Prescriptions Medication/Dose/How often	Reason for taking	Prescribing M.D.
1
2
3
4

Please list any allergies (Medications & food)
Some of our programs use medications that are not deemed safe to take while pregnant or breastfeeding.
YesNo
Females Only: What was the first day of your most recent menstrual cycle?

MonthDayYear
Signature:

Clear
Date:

MonthDayYear
Date

HIPPA ACKNOWLEDGMENT AND CONSENT
Signature:*

Clear
Date*

MonthDayYear
CONSENT TO TREAT
THIS CONSTITUTES INFORMED CONSENT FOR MEDICAL CARE
I hereby request and consent to the performance of specific testing and procedures on me (or the patient named below for which I am legally responsible) as deemed necessary by the providing physicians at any facility that DBA Options Medical Weight Loss. I wish to rely on the doctor and treating provider to exercise judgment during the course of the procedure, based on the facts then known is in my best interest. I have read, or have had read to me, the above consent. I have the opportunity to discuss the nature and purpose of the medical treatments and other procedures with the doctor and/or office personnel. I agree to these procedures and intend this consent form to cover the entire course of treatment and for any future condition(s) for which I seek treatment.
Patient Signature:*

Clear
Date*

MonthDayYear
Parent/Legal guardian name:
Guardian Signature:

Clear
Date:

MonthDayYear
Should be Empty:

PATIENT QUESTIONNAIRE