Grand Oak Healthcare
New Patient Intake Form
Health History
Full Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Occupation
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Address
Street Address
Suite or Apt #
City
State
Zip Code
Patient's Chief Complaint
Briefly describe your reason for seeking service with us.
Medication (List all medications you are currently taking)
Allergies (List all allergies)
Patient's Past History
Do you have or have you ever had the following? Check each box that is answered "Yes".
Headaches, dizziness, fainting
Blurred vision
Sinus trouble
Asthma
Sore throats
Shortness of breath
Persistent cough
Night sweats
Arthritis
Chest pain
High blood pressure
Heartburn or indigestion
Nausea and/or vomiting
Stroke
Ringing in Ears
Sudden weight gain or loss
Kidney disease or stones
Painful and/or difficult nutrition
Become tired or upset easily
Depression
Convulsions
Back pain or injury
Diabetes
Prior spinal surgeries
Other
* Please use the space below to explain any "yes" answers.
Serious Illness/Injuries/Hospitalizations
Please add the date and outcome.
Patient's Family & Social History
Do you use tobacco?
Yes
No
Amount/How Often
Do you use drugs?
Yes
No
Amount/How Often
Do you use alcohol?
Yes
No
Amount/How Often
Do you exercise regularly?
Yes
No
Amount/How Often
Family Relations
Rows
Age
State of Health
Serious Illness/Cause of Death
Father
Mother
Brother
Sister
Patient Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: