Patient Intake Form

SouthPointe Plaza

1901 E 32nd St. Ste. 20

Joplin MO

(417) 781-2046

www.apclinic.net
Patient Intake Form
Date

Month Day Year
Date
Patient Name *

First Name Middle Name Last Name
Preferred Name
Patient Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Birth Date *

Month Day Year
Phone *

Area Code Phone Number
Patient E-Mail
example@example.com
Occupation
How did you hear about our office?
Emergency Contact
Name
Relationship (to you)
Phone

Area Code Phone Number
Reason for your visit today
Is there any specific service and/or concern you would like to inquire about?
Reason for your visit today
What do you believe caused this problem?
When did this begin?
Is your concern constant or intermittent?
What makes it better?
What makes it worse?
What meds or treatments have you tried so far?
Describe how it feels.

If you have pain, rate on this scale

	1	2	3	4	5	6	7	8	9	10

1 is Lowest, 10 is Highest

Review of Systems
Constitutional

Fever/Chills Fatigue Sweats Unexpected weight changes Sleep disturbances
Head, Eyes, Ears, Nose, Throat

Vision Problem Decreased hearing Double vision Light sensitivity Itchy eyes Red eyes Eye pain Runny nose Neck stiffness Nosebleed Congestion Snoring Dry mouth Flu-like symptoms Sore throat Hoarseness Ringing in ears Vertigo Earache
Cardiovascular

Chest pain Cold hands or feet Irregular heart beat Palpitations Leg Swelling Leg pain w/walking
Respiratory

Shortness of breath Wheezing Coughing up blood Cough Rapid breathing Coughing up sputum Chest congestion
Gastrointestinal

Abdominal pain Diarrhea Jaundice (yellowing skin) Blood in stool or black/tarry stools Constipation Difficulty swallowing Nausea/Vomiting Loss of appetite Change in bowel habits Rectal pain Heartburn
Neurological

Headache Dizziness Decreased strength Poor coordination Disorientation Burning sensation Seizures Fainting Tremor Memory lapses/loss
Genitourinary

Frequent urination Incontinence Urinary urgency Painful urination Pelvic pain Nocturia Genital itching Change in libido Painful intercourse Vaginal discharge Vaginal bleeding Irregular menses Heavy menses
Integumentary

Rash Dry skin Skin wound Change in mole Unusual skin growth Itching Skin cancer
Psychiatric

Depression Anxiety Thoughts to harm self or others
Hematologic/Lymphatic

Bruises easily Bleeds easily Swollen lymph nodes
Endocrine

Excessive thirst Cold intolerance Heat intolerance Changes in hair Changes in skin
Do you have any allergies to medications or other substances (pet, food, etc.)?
If you have allergies to medications or other substances please list here
Please list ALL current medications, including over the counter meds, supplements and herbs
Are you currently under the care of a healthcare provider?

Yes No
Provider's Name
If yes, please explain
Do you use tobacco in any form?

Yes No
If yes, please list type and frequency of use

If Female, do you have any of these conditions?

	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?
Menopause
Hysterectomy
Tubal ligation

If you are pregnant, how many weeks?
Do you have any disease, condition or problem that you feel we should know about? If so, please describe
Signature of Patient or Legal Guardian

By signing this form I attest to the accuracy of the information provided to the best of my knowledge and hereby agree and give my consent to the practitioner to furnish medical care and treatment considered necessary and proper in diagnosing or treating my physical and/or mental condition.
Patient Signature *

Patient Signature Clear
Patient Name *

First Name Middle Name Last Name
Legal Guardian (if applicable)

First Name Last Name
Should be Empty:

Patient Intake Form

Emergency Contact

Reason for your visit today

Review of Systems

Signature of Patient or Legal Guardian