Medical Intake form
Name
*
First Name
Last Name
Person Filling Out This Form (if not the Patient)
First Name
Last Name
Relationship to the Patient
Phone
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
MM/DD/YYYY
Place of Birth
City/State or Town/Country if not in the US
Social Security #:
*
Gender
Male
Female
Physician's Information
Physician's Names/Addresses/Phone/Fax # (Please list all)
*
Date Applicant Last Saw Physician
*
MM/DD/YYYY
Date of last hospitalization
MM/DD/YYYY
Reason for hospitalization
How many times has applicant been hospitalized in the last year?
Tuberculosis
When was the last time you had a test for Tuberculosis?
MM/DD/YYYY
What was the result?
Have you ever had a positive test for Tuberculosis?
Yes
Unsure
No
If yes, did you complete ≥6 months of preventative treatment?
Yes
No
Unsure
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
Have you had known contact with someone known to have TB disease?
Yes
No
Vaccinations
Did you receive your childhood vaccinations?
*
Yes
No
Unknown
Yes
No
Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
COVID-19
Allergies
Do you have any allergies?
Yes
No
If yes, please list.
Do you have any drug allergies?
Yes
No
If yes, please list.
Medical History
Surgical History
Yes
No
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Other
Gastroenterology Related Medical History
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Other
Cardiology Related Medical History
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Endocrine Related Medical History
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Nephrology Related Medical History cont.
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Orthopedics Related Medical History cont.
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Immune System Related Medical History cont.
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Lung Related Medical History
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Cancer History
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Medical Health
Mental Health Condition History
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Please list any significant physical trauma you've experienced:
Please list emotional trauma you've experienced in your life:
Medications
Supplements
Use of assistive devices? (Glasses, hearing aids, cane, walker, etc.)
Signature
Should be Empty: