Medical Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email
example@example.com
3
Phone Number* This field is required.
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth
Date
Month
Day
Year
6
Gender
Please Select
Please Select
Male
Female
Non-binary
Genderqueer
Transgender
Agender
Two-Spirit
Genderfluid
Prefer not to say
7
Marital Status
Please Select
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
8
Name
First Name
Last Name
9
Phone Number
Please enter a valid phone number.
10
Relationship to Patient
Please Select
Please Select
Mother
Father
Sister
Brother
Friend
Cousin
Aunt
Uncle
11
Driver's License
12
Social Security Number
13
Type a question
Medication Name
Dosage
Frequency
Route/ Notes
1
Row 0, Column 0
Row 0, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 2, Column 2
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 3, Column 2
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 4, Column 2
Row 4, Column 3
6
Row 5, Column 0
Row 5, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 5, Column 2
Row 5, Column 3
7
Row 6, Column 0
Row 6, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 6, Column 2
Row 6, Column 3
8
Row 7, Column 0
Row 7, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 7, Column 2
Row 7, Column 3
9
Row 8, Column 0
Row 8, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 8, Column 2
Row 8, Column 3
10
Row 9, Column 0
Row 9, Column 1
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 9, Column 2
Row 9, Column 3
1
2
3
4
5
6
7
8
9
10
Medication Name
Row 0, Column 0
Dosage
Row 0, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 0, Column 2
Route/ Notes
Row 0, Column 3
Medication Name
Row 1, Column 0
Dosage
Row 1, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 1, Column 2
Route/ Notes
Row 1, Column 3
Medication Name
Row 2, Column 0
Dosage
Row 2, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 2, Column 2
Route/ Notes
Row 2, Column 3
Medication Name
Row 3, Column 0
Dosage
Row 3, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 3, Column 2
Route/ Notes
Row 3, Column 3
Medication Name
Row 4, Column 0
Dosage
Row 4, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 4, Column 2
Route/ Notes
Row 4, Column 3
Medication Name
Row 5, Column 0
Dosage
Row 5, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 5, Column 2
Route/ Notes
Row 5, Column 3
Medication Name
Row 6, Column 0
Dosage
Row 6, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 6, Column 2
Route/ Notes
Row 6, Column 3
Medication Name
Row 7, Column 0
Dosage
Row 7, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 7, Column 2
Route/ Notes
Row 7, Column 3
Medication Name
Row 8, Column 0
Dosage
Row 8, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 8, Column 2
Route/ Notes
Row 8, Column 3
Medication Name
Row 9, Column 0
Dosage
Row 9, Column 1
Frequency
Once daily
Twice daily
Three times daily
Four times daily
As needed (PRN)
Weekly
Every morning
Every evening
Row 9, Column 2
Route/ Notes
Row 9, Column 3
1 of 10
14
Type a question
Yes
No
Unknown
When
COVID
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Influenza (Flu)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Tetanus (TdaP)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Hepatitis A/B
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Pneumonia (Pneumovax)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Chicken pox (Varavax)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Shingles (Zostavax)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Meningitis
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
COVID
Influenza (Flu)
Tetanus (TdaP)
Hepatitis A/B
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Yes
Row 0, Column 0
No
Row 0, Column 1
Unknown
Row 0, Column 2
When
Row 0, Column 3
Yes
Row 1, Column 0
No
Row 1, Column 1
Unknown
Row 1, Column 2
When
Row 1, Column 3
Yes
Row 2, Column 0
No
Row 2, Column 1
Unknown
Row 2, Column 2
When
Row 2, Column 3
Yes
Row 3, Column 0
No
Row 3, Column 1
Unknown
Row 3, Column 2
When
Row 3, Column 3
Yes
Row 4, Column 0
No
Row 4, Column 1
Unknown
Row 4, Column 2
When
Row 4, Column 3
Yes
Row 5, Column 0
No
Row 5, Column 1
Unknown
Row 5, Column 2
When
Row 5, Column 3
Yes
Row 6, Column 0
No
Row 6, Column 1
Unknown
Row 6, Column 2
When
Row 6, Column 3
Yes
Row 7, Column 0
No
Row 7, Column 1
Unknown
Row 7, Column 2
When
Row 7, Column 3
1 of 8
15
Do you have any allergies to medications, foods, or other substances?
YESNO
16
Allergy
Reaction
Date of Occurence
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
1
2
3
4
Allergy
Row 0, Column 0
Reaction
Row 0, Column 1
Date of Occurence
Row 0, Column 2
Allergy
Row 1, Column 0
Reaction
Row 1, Column 1
Date of Occurence
Row 1, Column 2
Allergy
Row 2, Column 0
Reaction
Row 2, Column 1
Date of Occurence
Row 2, Column 2
Allergy
Row 3, Column 0
Reaction
Row 3, Column 1
Date of Occurence
Row 3, Column 2
1 of 4
17
Have you had any surgery in the last year?
YESNO
18
Surgery Type
Reason
Date of Surgery
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
1
2
3
Surgery Type
Row 0, Column 0
Reason
Row 0, Column 1
Date of Surgery
Row 0, Column 2
Surgery Type
Row 1, Column 0
Reason
Row 1, Column 1
Date of Surgery
Row 1, Column 2
Surgery Type
Row 2, Column 0
Reason
Row 2, Column 1
Date of Surgery
Row 2, Column 2
1 of 3
19
Have you ever been hospitalized
YESNO
20
Reason for Hospitalization
Date of Hospitalization
1
Row 0, Column 0
Row 0, Column 1
2
Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
1
2
3
Reason for Hospitalization
Row 0, Column 0
Date of Hospitalization
Row 0, Column 1
Reason for Hospitalization
Row 1, Column 0
Date of Hospitalization
Row 1, Column 1
Reason for Hospitalization
Row 2, Column 0
Date of Hospitalization
Row 2, Column 1
1 of 3
21
Medical Conditions
Yes
No
Date Diagnosed
Hypertension
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Cancers
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Coronary Artery Disease (CAD)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Congestive Heart Failure (CHF)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Myocardial Infarction (Heart Attack)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Atrial Fibrillation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Peripheral Artery Disease (PAD)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Stroke (CVA)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Diabetes Type 1
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Diabetes Type 2
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Irritable Bowel Syndrome (IBD)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Gastroesophageal Reflux Disease (GERD)
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Crohn's Disease
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
COPD
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Asthma
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Pneumonia
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Sleap Apnea
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Tuberculosis
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
High Cholesterol
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Rheumatoid Arthritis
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Eczema/Psoriasis
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Osteoporosis
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Fibromyalgia
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Systemic Lupus Erythematosus (Lupus)
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Back Pain (Chronic or Acute)
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Hyperthyroidism
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
Hypothyroidism
Row 26, Column 0
Row 26, Column 1
Row 26, Column 2
Migraine
Row 27, Column 0
Row 27, Column 1
Row 27, Column 2
Epilepsy
Row 28, Column 0
Row 28, Column 1
Row 28, Column 2
Multiple Sclerosis (MS)
Row 29, Column 0
Row 29, Column 1
Row 29, Column 2
Parkinson's Disease
Row 30, Column 0
Row 30, Column 1
Row 30, Column 2
Alzheimer's Disease
Row 31, Column 0
Row 31, Column 1
Row 31, Column 2
Neuropathy
Row 32, Column 0
Row 32, Column 1
Row 32, Column 2
Anemia
Row 33, Column 0
Row 33, Column 1
Row 33, Column 2
Chronic Kidney Disease (CKD)
Row 34, Column 0
Row 34, Column 1
Row 34, Column 2
Endometriosis
Row 35, Column 0
Row 35, Column 1
Row 35, Column 2
Prostate Enlargement (BPH)
Row 36, Column 0
Row 36, Column 1
Row 36, Column 2
HIV/AIDS
Row 37, Column 0
Row 37, Column 1
Row 37, Column 2
Glaucoma
Row 38, Column 0
Row 38, Column 1
Row 38, Column 2
Macular Degeneration
Row 39, Column 0
Row 39, Column 1
Row 39, Column 2
Cataracts
Row 40, Column 0
Row 40, Column 1
Row 40, Column 2
Hypertension
Cancers
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Myocardial Infarction (Heart Attack)
Atrial Fibrillation
Peripheral Artery Disease (PAD)
Stroke (CVA)
Diabetes Type 1
Diabetes Type 2
Irritable Bowel Syndrome (IBD)
Gastroesophageal Reflux Disease (GERD)
Crohn's Disease
COPD
Asthma
Pneumonia
Sleap Apnea
Tuberculosis
High Cholesterol
Rheumatoid Arthritis
Eczema/Psoriasis
Osteoporosis
Fibromyalgia
Systemic Lupus Erythematosus (Lupus)
Back Pain (Chronic or Acute)
Hyperthyroidism
Hypothyroidism
Migraine
Epilepsy
Multiple Sclerosis (MS)
Parkinson's Disease
Alzheimer's Disease
Neuropathy
Anemia
Chronic Kidney Disease (CKD)
Endometriosis
Prostate Enlargement (BPH)
HIV/AIDS
Glaucoma
Macular Degeneration
Cataracts
Yes
Row 0, Column 0
No
Row 0, Column 1
Date Diagnosed
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Date Diagnosed
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Date Diagnosed
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Date Diagnosed
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Date Diagnosed
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Date Diagnosed
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Date Diagnosed
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Date Diagnosed
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Date Diagnosed
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
Date Diagnosed
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
Date Diagnosed
Row 10, Column 2
Yes
Row 11, Column 0
No
Row 11, Column 1
Date Diagnosed
Row 11, Column 2
Yes
Row 12, Column 0
No
Row 12, Column 1
Date Diagnosed
Row 12, Column 2
Yes
Row 13, Column 0
No
Row 13, Column 1
Date Diagnosed
Row 13, Column 2
Yes
Row 14, Column 0
No
Row 14, Column 1
Date Diagnosed
Row 14, Column 2
Yes
Row 15, Column 0
No
Row 15, Column 1
Date Diagnosed
Row 15, Column 2
Yes
Row 16, Column 0
No
Row 16, Column 1
Date Diagnosed
Row 16, Column 2
Yes
Row 17, Column 0
No
Row 17, Column 1
Date Diagnosed
Row 17, Column 2
Yes
Row 18, Column 0
No
Row 18, Column 1
Date Diagnosed
Row 18, Column 2
Yes
Row 19, Column 0
No
Row 19, Column 1
Date Diagnosed
Row 19, Column 2
Yes
Row 20, Column 0
No
Row 20, Column 1
Date Diagnosed
Row 20, Column 2
Yes
Row 21, Column 0
No
Row 21, Column 1
Date Diagnosed
Row 21, Column 2
Yes
Row 22, Column 0
No
Row 22, Column 1
Date Diagnosed
Row 22, Column 2
Yes
Row 23, Column 0
No
Row 23, Column 1
Date Diagnosed
Row 23, Column 2
Yes
Row 24, Column 0
No
Row 24, Column 1
Date Diagnosed
Row 24, Column 2
Yes
Row 25, Column 0
No
Row 25, Column 1
Date Diagnosed
Row 25, Column 2
Yes
Row 26, Column 0
No
Row 26, Column 1
Date Diagnosed
Row 26, Column 2
Yes
Row 27, Column 0
No
Row 27, Column 1
Date Diagnosed
Row 27, Column 2
Yes
Row 28, Column 0
No
Row 28, Column 1
Date Diagnosed
Row 28, Column 2
Yes
Row 29, Column 0
No
Row 29, Column 1
Date Diagnosed
Row 29, Column 2
Yes
Row 30, Column 0
No
Row 30, Column 1
Date Diagnosed
Row 30, Column 2
Yes
Row 31, Column 0
No
Row 31, Column 1
Date Diagnosed
Row 31, Column 2
Yes
Row 32, Column 0
No
Row 32, Column 1
Date Diagnosed
Row 32, Column 2
Yes
Row 33, Column 0
No
Row 33, Column 1
Date Diagnosed
Row 33, Column 2
Yes
Row 34, Column 0
No
Row 34, Column 1
Date Diagnosed
Row 34, Column 2
Yes
Row 35, Column 0
No
Row 35, Column 1
Date Diagnosed
Row 35, Column 2
Yes
Row 36, Column 0
No
Row 36, Column 1
Date Diagnosed
Row 36, Column 2
Yes
Row 37, Column 0
No
Row 37, Column 1
Date Diagnosed
Row 37, Column 2
Yes
Row 38, Column 0
No
Row 38, Column 1
Date Diagnosed
Row 38, Column 2
Yes
Row 39, Column 0
No
Row 39, Column 1
Date Diagnosed
Row 39, Column 2
Yes
Row 40, Column 0
No
Row 40, Column 1
Date Diagnosed
Row 40, Column 2
1 of 41
22
Does anyone in your immediate family have a history of serious illness (e.g., Cancer, Diabetes, Heart Disease)?
YESNO
23
Relationship to Patient
Medical Condition
1
Row 0, Column 0
Row 0, Column 1
2
Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
4
Row 3, Column 0
Row 3, Column 1
1
2
3
4
Relationship to Patient
Row 0, Column 0
Medical Condition
Row 0, Column 1
Relationship to Patient
Row 1, Column 0
Medical Condition
Row 1, Column 1
Relationship to Patient
Row 2, Column 0
Medical Condition
Row 2, Column 1
Relationship to Patient
Row 3, Column 0
Medical Condition
Row 3, Column 1
1 of 4
24
Do you smoke or use tobacco?
YESNO
25
How many per day?
26
Start/ Stop Date
Date
Year
Month
Day
27
Alchohol Use
YESNO
28
How many drinks per week?
29
Recreational Drugs
YESNO
30
Do you experience any of the following
None
Anxiety
Depression
Sleep disorders
Stress
Other
31
Are you currently taking any mental health medications?
YESNO
32
Medications for Mental Health
Medication Name
Dosage
Frequency
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
1
2
3
4
Medication Name
Row 0, Column 0
Dosage
Row 0, Column 1
Frequency
Row 0, Column 2
Medication Name
Row 1, Column 0
Dosage
Row 1, Column 1
Frequency
Row 1, Column 2
Medication Name
Row 2, Column 0
Dosage
Row 2, Column 1
Frequency
Row 2, Column 2
Medication Name
Row 3, Column 0
Dosage
Row 3, Column 1
Frequency
Row 3, Column 2
1 of 4
33
Specify your childbearing status
Person of Childbearing Potential
Post-Menopausal
Surgically Sterile
Male
34
Person of Childbearing Potential – Last Menses Date
Date
Year
Month
Day
35
Post-Menopausal – Last Menses Date
Date
Year
Month
Day
36
Surgically Sterile – Type & Date
Huge
Large
Normal
Small
Ok
Ok
37
Are you currently using any form of contraception?
YESNO
38
Contraceptive Method
39
Start Date
Date
Year
Month
Day
40
Are you currently pregnant, planning to become pregnant, or breastfeeding?
YESNO
41
Have you had any pregnancies in the past?
YESNO
42
Pregnancy Dates
Huge
Large
Normal
Small
Ok
Ok
43
How Many?
44
Do you have a Primary Care Provider?
YESNO
45
PCP Name
46
PCP Phone Number
Please enter a valid phone number.
47
PCP Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
48
Last Visit Date
Date
Year
Month
Day
49
Reason for Last Visit
Huge
Large
Normal
Small
Ok
Ok
50
Other Specialists You Are Currently Seeing
YESNO
51
Specialist
52
Specialist Name
53
Specialist Phone Number
Please enter a valid phone number.
54
Any concerns or information to share with the research team?
YESNO
55
Please explain
Huge
Large
Normal
Small
Ok
Ok
56
SignatureI hereby authorize Pioneer Clinical Studies, Inc., to obtain and store the health information provided in this Medical Intake Form. This information may be stored electronically in the electronic medical records system of Pioneer Clinical Studies and used for healthcare management, treatment, and evaluation for potential study participation. The information released in response to this authorization may be re-disclosed to other Business Associates. By signing this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I have the right to revoke this authorization in writing at any time, except to the extent that actions have already been taken based on this consent. By signing below, I acknowledge that I have read, understood, and agreed to the terms outlined in this document.
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