Patient Intake Form

SouthPointe Plaza

1901 E 32nd St. Ste. 20

Joplin MO

(417) 781-2046

www.apclinic.net
Patient Intake Form
Date

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Preferred Name
Patient Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Birth Date*

MonthDayYear
Phone*

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

Area CodePhone 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/ChillsFatigueSweatsUnexpected weight changesSleep disturbances
Head, Eyes, Ears, Nose, Throat

Vision ProblemDecreased hearingDouble visionLight sensitivityItchy eyesRed eyesEye painRunny noseNeck stiffnessNosebleedCongestionSnoringDry mouthFlu-like symptomsSore throatHoarsenessRinging in earsVertigoEarache
Cardiovascular

Chest painCold hands or feetIrregular heart beatPalpitationsLeg SwellingLeg pain w/walking
Respiratory

Shortness of breathWheezingCoughing up bloodCoughRapid breathingCoughing up sputumChest congestion
Gastrointestinal

Abdominal painDiarrheaJaundice (yellowing skin)Blood in stool or black/tarry stoolsConstipationDifficulty swallowingNausea/VomitingLoss of appetiteChange in bowel habitsRectal painHeartburn
Neurological

HeadacheDizzinessDecreased strengthPoor coordinationDisorientationBurning sensationSeizuresFaintingTremorMemory lapses/loss
Genitourinary

Frequent urinationIncontinenceUrinary urgencyPainful urinationPelvic painNocturiaGenital itchingChange in libidoPainful intercourseVaginal dischargeVaginal bleedingIrregular mensesHeavy menses
Integumentary

RashDry skinSkin woundChange in moleUnusual skin growthItchingSkin cancer
Psychiatric

DepressionAnxietyThoughts to harm self or others
Hematologic/Lymphatic

Bruises easilyBleeds easilySwollen lymph nodes
Endocrine

Excessive thirstCold intoleranceHeat intoleranceChanges in hairChanges 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?

YesNo
Provider's Name
If yes, please explain
Do you use tobacco in any form?

YesNo
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 NameMiddle NameLast Name
Legal Guardian (if applicable)

First NameLast Name
Should be Empty:

Patient Intake Form

Emergency Contact

Reason for your visit today

Review of Systems

Signature of Patient or Legal Guardian