Patient Intake Form

History of Present Illness

Version 03.12.26

Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Pharmacy Details

Pharmacy Name

Street Address

CityState / Province

Postal / Zip Code
Pharmacy Phone Number

Area CodePhone Number
Comments

Height
Weight
Which best describes the main reason for TODAY'S visit?

Other
Choose any other conditions you want to discuss at FUTURE visits (select all that apply)

Other
Are you allergic to the following? (Select all that apply)

Other
List all MEDICATION ALLERGIES (Name of Medication-Reaction to Medication)
List all HOSPITALIZATIONS, including the year (not ER visits)
List all SURGERIES. (Select all that apply)
List all surgeries not mentioned above. (Please specify)
Please select if you have been diagnosed with or have a history of any of the following conditions:

Other
OTHERS (Please list down all the past medical conditions)
I authorize Metro Atlanta Urology and Pelvic Health Center to retrieve my external prescription history

Please List All Medications

Rows	Medication Name	Dosage Amount	#Taken Daily	Ordering Doctor	Start Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Tobacco Usage:
How many packs per day?
How many years?
Have you tried to quit?
Alcohol Consumption
Caffeine Consumption
Number of Pregnancies
Number of children born
Are you currently pregnant?
Marital Status
What is your current living arrangement?
Do you have an Advanced Directive?
Do any one of your family members have any of the following: