Patient Intake Form
Name
First Name
Last Name
DOB (date of birth)
-
Month
-
Day
Year
Date
Reason for visit?
Please briefly describe reason for visit in the blank box above.
Current Medications
Please inform us on any current medication being taken, if none leave the box blank.
Allergies (are you allergic to any of the following?)
Adhesive Tape
Barbiturates (sleeping pills)
Codeine
Antibiotics
Aspirin
Sulfa
Latex
Iodine
Local Anesthetics
Other
Medical History
Alcoholism
Allergies
Anemia
Anxiety disorder
Arthritis
Asthma
AIDS/HIV
Back problem
Bleeding disorder
Blood disease
Blood tranfusion
Cancer
Diabetes
Depression
Ear problem ( deaf)
Eating disorder
epilepsy
Glaucoma
Gout
Heart diseas
Heart Issues
Hepatitis A,B,C
High blood pressure
High cholestral
Joint disorder
Kidney Disorder
Liver Disorder
Lung disease
Measles
Osteoporosis
Pneumia
Polio
Fevers
Stroke
Skin disorder
Stomach ulcer
Thyroid disorder
Tuberculosis
Venereal Disease
Any Hospitalizations & Surgeries?
Describe Any recent surgeries or medical procedures if any.
Any Hospitalizations & Surgeries?
Describe Any recent surgeries or medical procedures if any.
Family Medical History
Please describe any family medical history ex: diabetes, cancer, heart attacks, etc.
Has anyone in your home physically or verbally hurt you?
Yes
No
Have you ever smoked?
Yes
No
Do you use recreational drugs?
Yes
No
How much alcohol do you drink in a week?
ex: Two drinks per week
How much caffeine do you drink per day?
Ex: 1 Cup
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Email
example@example.com
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MEDICAL RECORDS AND IMAGES
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INSURANCE CARDS
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This section is intended for woman only
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