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Welcome to our Medical Intake Form
Please set aside approximately 15 minutes to complete this form. Thoughtfully consider these questions and answer to the best of your knowledge.
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HIPAA
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Language
English (US)
Spanish (Latin America)
1
Name
First Name
Last Name
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2
Person Filling Out This Form (if not the Patient)
First Name
Last Name
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3
Relationship to the Patient
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4
Email
example@example.com
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5
Phone Number
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6
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
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7
Date of Birth
-
Date
Month
Day
Year
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8
Place of Birth
City/State or Town/Country if not in the US
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9
Gender
Please Select
Male
Female
Non-binary
Genderqueer
Transgender
Agender
Two-Spirit
Genderfluid
Prefer not to say
Please Select
Please Select
Male
Female
Non-binary
Genderqueer
Transgender
Agender
Two-Spirit
Genderfluid
Prefer not to say
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10
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Please Select
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
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11
Name
First Name
Last Name
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12
Phone Number
Please enter a valid phone number.
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13
When was the last time you had a test for Tuberculosis?
-
Date
Month
Day
Year
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14
What was the result?
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15
Have you ever had a positive test for Tuberculosis?
Yes
Unsure
No
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16
If yes, did you complete ≥6 months of preventative treatment?
Yes
No
Unsure
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17
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
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18
Have you had known contact with someone known to have TB disease?
Yes
No
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19
Did you receive your childhood vaccinations?
Yes
No
Unknown
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20
Type a question
Yes
No
Unknown
HPV (Gardasil)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Tetanus (TdaP)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Hepatitis A
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Hepatitis B
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Influenza (Flu)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Pneumonia (Pneumovax)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Chicken pox (Varavax)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Shingles (Zostavax)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Meningitis
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Yes
Row 0, Column 0
No
Row 0, Column 1
Unknown
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Unknown
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Unknown
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Unknown
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Unknown
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Unknown
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Unknown
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Unknown
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Unknown
Row 8, Column 2
1
of 9
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21
Do you have any allergies?
Yes
No
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22
If yes, please list.
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23
Do you have any drug allergies?
Yes
No
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24
If yes, please list.
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25
What is your sexuality?
Heterosexual
Gay
Lesbian
Bisexual
N/A
Other
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26
Have you had the tests below?
Yes
No
Unsure
Cervical Pap Smear
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Anal Pap Smear
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
HIV Test
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Hepatitis C Test
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test
Yes
Row 0, Column 0
No
Row 0, Column 1
Unsure
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Unsure
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Unsure
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Unsure
Row 3, Column 2
1
of 4
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27
Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
Yes
No
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28
If yes, please check all that apply
Not Satisfied
Somewhat Satisfied
Satisfied
HIV/AIDS
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Gonorrhea
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Chlamydia
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Oral Herpes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Yeast Infection
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Syphilis
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis
Not Satisfied
Row 0, Column 0
Somewhat Satisfied
Row 0, Column 1
Satisfied
Row 0, Column 2
Not Satisfied
Row 1, Column 0
Somewhat Satisfied
Row 1, Column 1
Satisfied
Row 1, Column 2
Not Satisfied
Row 2, Column 0
Somewhat Satisfied
Row 2, Column 1
Satisfied
Row 2, Column 2
Not Satisfied
Row 3, Column 0
Somewhat Satisfied
Row 3, Column 1
Satisfied
Row 3, Column 2
Not Satisfied
Row 4, Column 0
Somewhat Satisfied
Row 4, Column 1
Satisfied
Row 4, Column 2
Not Satisfied
Row 5, Column 0
Somewhat Satisfied
Row 5, Column 1
Satisfied
Row 5, Column 2
1
of 6
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29
Family History
Mother
Father
Sibling
Children
Maternal Grandparent
Paternal Grandparent
Cancers
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Colon
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Breast/Ovarian
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Heart Disease
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Hypertension
Row 4, Column 0
Row 4, Column 1
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Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Obesity
Row 5, Column 0
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Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Diabetes
Row 6, Column 0
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Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Stroke
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Row 7, Column 5
Inflammatory arthritis
Row 8, Column 0
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Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Inflammatory Bowel Disease
Row 9, Column 0
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Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Multiple Sclerosis
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Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
Autoimmune Diseases
Row 11, Column 0
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Row 11, Column 3
Row 11, Column 4
Row 11, Column 5
Irritable Bowel Syndrome
Row 12, Column 0
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Row 12, Column 5
Celiac Disease
Row 13, Column 0
Row 13, Column 1
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Row 13, Column 3
Row 13, Column 4
Row 13, Column 5
Asthma
Row 14, Column 0
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Row 14, Column 5
Eczema/Psoriasis
Row 15, Column 0
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Row 15, Column 3
Row 15, Column 4
Row 15, Column 5
Food allergies/sensitivities
Row 16, Column 0
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Row 16, Column 3
Row 16, Column 4
Row 16, Column 5
Environmental sensitivities
Row 17, Column 0
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Row 17, Column 3
Row 17, Column 4
Row 17, Column 5
Dementia
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
Row 18, Column 5
Parkinson's
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Row 19, Column 5
ALS or other motor neuron diseases
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Row 20, Column 5
Genetic disorders
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Row 21, Column 5
Substance abuse (alcoholism, etc.)
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Row 22, Column 5
Psychiatric disorders
Row 23, Column 0
Row 23, Column 1
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Row 23, Column 3
Row 23, Column 4
Row 23, Column 5
Depression
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Row 24, Column 3
Row 24, Column 4
Row 24, Column 5
Schizophrenia
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
Row 25, Column 3
Row 25, Column 4
Row 25, Column 5
ADHD
Row 26, Column 0
Row 26, Column 1
Row 26, Column 2
Row 26, Column 3
Row 26, Column 4
Row 26, Column 5
Austism
Row 27, Column 0
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Row 27, Column 3
Row 27, Column 4
Row 27, Column 5
Bipolar disease
Row 28, Column 0
Row 28, Column 1
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Row 28, Column 3
Row 28, Column 4
Row 28, Column 5
Other
Row 29, Column 0
Row 29, Column 1
Row 29, Column 2
Row 29, Column 3
Row 29, Column 4
Row 29, Column 5
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Other
Mother
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Father
Row 0, Column 1
Sibling
Row 0, Column 2
Children
Row 0, Column 3
Maternal Grandparent
Row 0, Column 4
Paternal Grandparent
Row 0, Column 5
Mother
Row 1, Column 0
Father
Row 1, Column 1
Sibling
Row 1, Column 2
Children
Row 1, Column 3
Maternal Grandparent
Row 1, Column 4
Paternal Grandparent
Row 1, Column 5
Mother
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Father
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Sibling
Row 2, Column 2
Children
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Maternal Grandparent
Row 2, Column 4
Paternal Grandparent
Row 2, Column 5
Mother
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Father
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Sibling
Row 3, Column 2
Children
Row 3, Column 3
Maternal Grandparent
Row 3, Column 4
Paternal Grandparent
Row 3, Column 5
Mother
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Father
Row 4, Column 1
Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
Row 10, Column 5
Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
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Paternal Grandparent
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Mother
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Father
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Sibling
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Children
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Maternal Grandparent
Row 21, Column 4
Paternal Grandparent
Row 21, Column 5
Mother
Row 22, Column 0
Father
Row 22, Column 1
Sibling
Row 22, Column 2
Children
Row 22, Column 3
Maternal Grandparent
Row 22, Column 4
Paternal Grandparent
Row 22, Column 5
Mother
Row 23, Column 0
Father
Row 23, Column 1
Sibling
Row 23, Column 2
Children
Row 23, Column 3
Maternal Grandparent
Row 23, Column 4
Paternal Grandparent
Row 23, Column 5
Mother
Row 24, Column 0
Father
Row 24, Column 1
Sibling
Row 24, Column 2
Children
Row 24, Column 3
Maternal Grandparent
Row 24, Column 4
Paternal Grandparent
Row 24, Column 5
Mother
Row 25, Column 0
Father
Row 25, Column 1
Sibling
Row 25, Column 2
Children
Row 25, Column 3
Maternal Grandparent
Row 25, Column 4
Paternal Grandparent
Row 25, Column 5
Mother
Row 26, Column 0
Father
Row 26, Column 1
Sibling
Row 26, Column 2
Children
Row 26, Column 3
Maternal Grandparent
Row 26, Column 4
Paternal Grandparent
Row 26, Column 5
Mother
Row 27, Column 0
Father
Row 27, Column 1
Sibling
Row 27, Column 2
Children
Row 27, Column 3
Maternal Grandparent
Row 27, Column 4
Paternal Grandparent
Row 27, Column 5
Mother
Row 28, Column 0
Father
Row 28, Column 1
Sibling
Row 28, Column 2
Children
Row 28, Column 3
Maternal Grandparent
Row 28, Column 4
Paternal Grandparent
Row 28, Column 5
Mother
Row 29, Column 0
Father
Row 29, Column 1
Sibling
Row 29, Column 2
Children
Row 29, Column 3
Maternal Grandparent
Row 29, Column 4
Paternal Grandparent
Row 29, Column 5
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Surgical History
Yes
No Satisfied
Appendix Removal
Row 0, Column 0
Row 0, Column 1
Mastectomy
Row 1, Column 0
Row 1, Column 1
C-Section
Row 2, Column 0
Row 2, Column 1
Hysterectomy
Row 3, Column 0
Row 3, Column 1
Phalloplasty
Row 4, Column 0
Row 4, Column 1
Tonsillectomy
Row 5, Column 0
Row 5, Column 1
Coronary Artery Bypass Grafting
Row 6, Column 0
Row 6, Column 1
Angioplasty and/or Stent
Row 7, Column 0
Row 7, Column 1
Knee Replacement
Row 8, Column 0
Row 8, Column 1
Hip Replacement
Row 9, Column 0
Row 9, Column 1
Hernia Repair
Row 10, Column 0
Row 10, Column 1
Pacemaker
Row 11, Column 0
Row 11, Column 1
None
Row 12, Column 0
Row 12, Column 1
Appendix Removal
Mastectomy
C-Section
Hysterectomy
Phalloplasty
Tonsillectomy
Coronary Artery Bypass Grafting
Angioplasty and/or Stent
Knee Replacement
Hip Replacement
Hernia Repair
Pacemaker
None
Yes
Row 0, Column 0
No Satisfied
Row 0, Column 1
Yes
Row 1, Column 0
No Satisfied
Row 1, Column 1
Yes
Row 2, Column 0
No Satisfied
Row 2, Column 1
Yes
Row 3, Column 0
No Satisfied
Row 3, Column 1
Yes
Row 4, Column 0
No Satisfied
Row 4, Column 1
Yes
Row 5, Column 0
No Satisfied
Row 5, Column 1
Yes
Row 6, Column 0
No Satisfied
Row 6, Column 1
Yes
Row 7, Column 0
No Satisfied
Row 7, Column 1
Yes
Row 8, Column 0
No Satisfied
Row 8, Column 1
Yes
Row 9, Column 0
No Satisfied
Row 9, Column 1
Yes
Row 10, Column 0
No Satisfied
Row 10, Column 1
Yes
Row 11, Column 0
No Satisfied
Row 11, Column 1
Yes
Row 12, Column 0
No Satisfied
Row 12, Column 1
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Gastroenterology Related Medical History
Gastrointestinal:
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Crohn's
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Ulcerative colitis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Peptic Ulcer disease
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
GERD (reflux)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Celiac disease
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Other
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
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Cardiology Related Medical History
Cardiovascular
Past condition
Ongoing condition
N/A
Heart Failure
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Heart Attack
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Other Heart disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Stroke
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Elevated cholesterol
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Arrhythmia (irregular heart rate)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Hypertension (high blood pressure)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Hypotension (low blood pressure)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Rheumatic fever
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Mitral valve prolapse
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Other
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Heart Failure
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Hypotension (low blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
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Endocrine Related Medical History
Metabolic/Endocrine
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Type 2 Diabetes
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Hypoglycemia
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Metabolic syndrome (pre-diabetes)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Hypothyroidism (low thyroid)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Hyperthyroidism (overactive thyroid)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Polycystic Ovarian Syndrome
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Infertility
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Weight gain
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Weight loss
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Eating disorder
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Other
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
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
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
Past condition
Row 11, Column 0
Ongoing condition
Row 11, Column 1
N/A
Row 11, Column 2
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Nephrology Related Medical History cont.
Genital & Urinary system
Past conditon
Ongoing condition
N/A
Chronic Kidney Disease
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Kidney stones
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Gout
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Interstitial cystitis
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Frequent urinary tract infections
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Frequent yeast infections
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Erectile dysfunction
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Sexual dysfunction
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Other
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Chronic Kidney Disease
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Past conditon
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past conditon
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past conditon
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past conditon
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past conditon
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past conditon
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past conditon
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past conditon
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past conditon
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
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Orthopedics Related Medical History cont.
Musculoskeletal/Pain
Past condition
Ongoing condition
N/A
Osteoarthritis
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Fibromyalgia
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Chronic pain
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Other
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
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Immune System Related Medical History cont.
Inflammatory/Autoimmune
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Autoimmune disease
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Rheumatoid arthritis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Lupus SLE
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Immune deficiency disease
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Severe infectious disease
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Poor Immune function
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Other
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
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Lung Related Medical History
Respiratory
Past condition
Ongoing condition
N/A
Asthma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
COPD
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Chronic Cough
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Chronic sinusitis
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Bronchitis
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Emphysema
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Pneumonia
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Tuberculosis
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Sleep Apnea
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Other
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Asthma
COPD
Chronic Cough
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
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Cancer History
Skin
Past condition
Ongoing condition
N/A
Skin Cancer
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Lung Cancer
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Breast Cancer
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Colon Cancer
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Ovarian Cancer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Prostate Cancer
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Other
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Skin Cancer
Lung Cancer
Breast Cancer
Colon Cancer
Ovarian Cancer
Prostate Cancer
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
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Mental Health Condition History
Neurological
Past condition
Ongoing condition
N/A
Depression
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Anxiety
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Bipolar disorder
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Schizophrenia
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Headaches
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Migraines
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
ADD/ADHD
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Autism
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Memory problems
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Dementia/Alzheimer's
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Parkinson's disease
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Multiple Sclerosis
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Seizures
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Other
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
Past condition
Row 11, Column 0
Ongoing condition
Row 11, Column 1
N/A
Row 11, Column 2
Past condition
Row 12, Column 0
Ongoing condition
Row 12, Column 1
N/A
Row 12, Column 2
Past condition
Row 13, Column 0
Ongoing condition
Row 13, Column 1
N/A
Row 13, Column 2
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Please list any significant physical trauma you've experienced
(i.e. car accidents, sport injuries, head injuries, etc.)
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
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Medication history
Prolonged or frequent use of the following classes of medications
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Tylenol (Acetaminophen)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Antibiotics
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Steriods
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Oral contraceptives
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Other
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Other
Currently
Row 0, Column 0
Past use
Row 0, Column 1
Rarely used
Row 0, Column 2
Never
Row 0, Column 3
Currently
Row 1, Column 0
Past use
Row 1, Column 1
Rarely used
Row 1, Column 2
Never
Row 1, Column 3
Currently
Row 2, Column 0
Past use
Row 2, Column 1
Rarely used
Row 2, Column 2
Never
Row 2, Column 3
Currently
Row 3, Column 0
Past use
Row 3, Column 1
Rarely used
Row 3, Column 2
Never
Row 3, Column 3
Currently
Row 4, Column 0
Past use
Row 4, Column 1
Rarely used
Row 4, Column 2
Never
Row 4, Column 3
Currently
Row 5, Column 0
Past use
Row 5, Column 1
Rarely used
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42
Medications
Please number and list all your current prescription medications:
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43
Supplements
Please number and list any/all current supplements:
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Signature
I 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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