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
Insurance Card (Front)
Insurance Card (End)
Check all symptoms that apply

Sad/depressed moodLoss of interest/pleasureFeeling worthless/guiltWithdrawn/Social IsolationIrritability/outbursts of angerWeight gain/lossAppetite increase/decreaseSleep disturbanceCrying spellsDifficulty concentratingInflated self-esteemGrandiosityTalkativeFlight of ideasDistractibilityUnrestrained buying spreesSexual indiscretionsExcessive pleasure activitiesMuscle tensionHeart palpitationsSweating not due to heatTrembling/shakingShortness of breathFeeling of chokingChest pain/discomfortFeeling dizzy/lightheadedCompulsionsFear of losing controlRecurrent/persistent thoughtsRecurrent/intrusive memoriesLaxative/diuretic abuseTrouble following directionsTouchy/easily annoyedThoughts of SuicideHomicidal IdeationPoor impulse controlRelationship difficultiesDeliberate property destructionOther
List any chronic health problems you may have
List out all current medication
List out allergies
Have you received any outpatient treatment for a psychiatric condition ?

YesNo
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?
Average hour of sleep per week?
Average # of workouts per week?
Date

MonthDayYear
Date
Signature

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