Medical Patient Intake Form

Patient Intake Form
Name

First NameLast Name
Birth Date

MonthDayYear
Date
FemaleMale
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Insurance Provider
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
YesNo
None0 -1 package a day1 - 2 packages a day2+ packages a day
Average # alcoholic drinks per week?
Date
Signature
Should be Empty: