Medical Patient Intake Form

Patient Intake Form
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender

FemaleMale
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Insurance Provider
Check all symptoms that apply

Sore throatLoss of interest/pleasureFeverWeight gain/lossAppetite increase/decreaseSleep disturbanceNauseaDifficulty concentratingVomitingHeadacheHeartburnBack PainMuscle tensionHeart palpitationsSweating not due to heatTrembling/shakingShortness of breathFrequent urinationChest pain/discomfortFeeling dizzy/lightheadedDiarrheaConstipatedBody AchesAllergy/Sinus symptomsThoughts of SuicideChillsAnxietyOther
List any chronic health problems you may have
List out all current medication
Allergies
Have you been hospitalized?

YesNo
Please select the option that apply regarding your smoking habits

None0 -1 package a day1 - 2 packages a day2+ packages a day
Average # alcoholic drinks per week?
Date
Signature
Should be Empty: