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 DISEASE STROKE HYPERTENSION HYPOTENSION HYPERCHOLESTEROLEMIA HYPERLIPIDEMIA SEIZURES CANCER MAJOR INFECTION ASTHMA LUNG DISEASE DIABETES MIGRAINE HEADACHES KIDNEY DISEASE THYROID DISEASE HEPATITIS TUBERCULOSIS GLAUCOMA HIV ULCERS DEPRESSION ANXIETY ARTHRITIS ANEMIA BACK 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 DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
FATHER Alive or Deceased?
FATHER Age?
MOTHER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
MOTHER Alive or Deceased?
MOTHER Age?
BROTHER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
BROTHER Alive or Deceased?
BROTHER Age?
SISTER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
SISTER Alive or Deceased?
SISTER Age?
SON MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
SON Alive or Deceased?
SON Age?
DAUGHTER MEDICAL HISTORY (CHECK ALL THAT APPLY):

HEART DISEASE STROKE HYPERTENSION CANCER DIABETES MIGRAINE HEADACHES UNKNOWN
DAUGHTER Alive or Deceased?
DAUGHTER Age?
SURGICAL HISTORY: (LIST PROCEDURE AND DATE)
USE OF TOBACCO

NEVER USE PREVIOUSLY BUT QUIT YES
PACKS/DAY
USE OF ALCOHOL

NEVER USE PREVIOUSLY BUT QUIT YES
AMOUNT
USE OF RECREATIONAL DRUGS

NEVER USE PREVIOUSLY BUT QUIT YES
WHAT
WORK STATUS

Employed Unemployed Disabled Retired
Should be Empty: