Medical Intake Form

PATIENT NAME
DOB
Reason for Visit
Phone
Email
PHARMACY NAME
PHARMACY ADDRESS:
PLEASE LIST ANY ALLERGIES
PLEASE PROVIDE A COPY OF YOUR MEDICATIONS INCLUDING DOSAGE AND FREQUENCY OR LIST HERE
MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONHYPOTENSIONHYPERCHOLESTEROLEMIAHYPERLIPIDEMIASEIZURESCANCERMAJOR INFECTIONASTHMALUNG DISEASEDIABETESMIGRAINE HEADACHESKIDNEY DISEASETHYROID DISEASEHEPATITISTUBERCULOSISGLAUCOMAHIVULCERSDEPRESSIONANXIETYARTHRITISANEMIABACK TROUBLE
LIST ANY OTHER DISEASES
FAMILY MEDICAL HISTORY

Please indicate if your family members have any of the following conditions:

diabetes
hypertension
heart disease
stroke
migraine
unknown

Please include their current status and age.
FATHER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
FATHER Alive or Deceased?
FATHER Age?
MOTHER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
MOTHER Alive or Deceased?
MOTHER Age?
BROTHER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
BROTHER Alive or Deceased?
BROTHER Age?
SISTER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
SISTER Alive or Deceased?
SISTER Age?
SON MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
SON Alive or Deceased?
SON Age?
DAUGHTER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASESTROKEHYPERTENSIONCANCERDIABETESMIGRAINE HEADACHESUNKNOWN
DAUGHTER Alive or Deceased?
DAUGHTER Age?
SURGICAL HISTORY: (LIST PROCEDURE AND DATE)
USE OF TOBACCO

NEVER USEPREVIOUSLY BUT QUITYES
PACKS/DAY
USE OF ALCOHOL

NEVER USEPREVIOUSLY BUT QUITYES
AMOUNT
USE OF RECREATIONAL DRUGS

NEVER USEPREVIOUSLY BUT QUITYES
WHAT
WORK STATUS

EmployedUnemployedDisabledRetired
Should be Empty: