Patient Intake Form
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Insurance Provider
Check all symptoms that apply
Sore throat
Loss of interest/pleasure
Fever
Weight gain/loss
Appetite increase/decrease
Sleep disturbance
Nausea
Difficulty concentrating
Vomiting
Headache
Heartburn
Back Pain
Muscle tension
Heart palpitations
Sweating not due to heat
Trembling/shaking
Shortness of breath
Frequent urination
Chest pain/discomfort
Feeling dizzy/lightheaded
Diarrhea
Constipated
Body Aches
Allergy/Sinus symptoms
Thoughts of Suicide
Chills
Anxiety
Other
List any chronic health problems you may have
List out all current medication
Allergies
Have you been hospitalized?
Yes
No
Please select the option that apply regarding your smoking habits
None
0 -1 package a day
1 - 2 packages a day
2+ packages a day
Average # alcoholic drinks per week?
Date
Signature
Should be Empty: