Patient Intake Form

Patient Intake Form

Please complete in its entirety. If you are unsure, please leave the question blank. Thank you.
Patient Name

First NameMiddle NameLast Name
Nickname(s) you go by
Date of birth

MonthDayYear
How did you hear about us?
Contact Information
Home Address:

Street Address

Street Address Line 2

CityCounty/State/Province

Zip Code
Contact Name(s) on behalf of the Patient

First NameLast Name
Contact Name(s) on behalf of the Patient

First NameLast Name
E-mail that we will use to regularly communicate with you

Confirmation Email
Secondary e-mail

Confirmation Emailexample@example.com
Preferred phone number(s) for voice and/or text communication

Phone numberPhone Number

Health Assessment and Medical Information
Current Height
Current Weight
Are you taking any prescription medications?

YesNo
Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?

YesNo
Please list your medications below. Add additional medications by selecting the green plus to insert a new medication box.
Any known allergies? Please list any allergies and include the reaction.

Is there anything else you would like to add that you feel is important and has not been covered? Please add any hobbies or activities you would like us to know about.
Today's Date

DayMonthYear
Thanks for taking the time to complete this intake form.
Should be Empty:

Contact Information