Patient Intake Form

Patient Intake Form
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age*
Gender*
Home Phone
Cell Phone
Please Contact By*

HomeCell
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Name
Pharmacy City
Insurance
Previous Provider (Doctor)
Medical History

Conditions

	You	Father	Mother	Sibling	Other
Anxiety
Asthma
Arthritis
Cancer
COPD
Depression
Diabetes - Type 1
Diabetes - Type 2
Heart Attack
Heart Disease
Heart Failure
Hepatitis
High Blood Pressure
High Cholesterol
Urinary Problems
Kidney Problems
Liver Problems
Migraines
Prostate Problems
Stroke
Thyroid Problems

Medications
May provide list or bring in bottles. Select "Add Medication" to add additional medications.
Allergies
Please list any allergies. Select "Add Allergy" to add additional allergies.
Surgical History
Please list any previous surgies. Select "Add Surgery" to add additional surgeries.
Tests

MammogramPap SmearBone DensityColonoscopyEye ExamProstate ExamStress TestHearing TestFoot ExamEKG
Mammogram Approximate Date*

MonthDayYear
Pap Smear Approximate Date*

MonthDayYear
Bone Density Approximate Date*

MonthDayYear
Colonoscopy Approximate Date*

MonthDayYear
Eye Exam Approximate Date*

MonthDayYear
Prostate Exam Approximate Date*

MonthDayYear
Stress Test Approximate Date*

MonthDayYear
Hearing Test Approximate Date*

MonthDayYear
Foot Exam Approximate Date*

MonthDayYear
EKG Approximate Date*

MonthDayYear
Vaccines

PneumoniaShinglesTetanusFlu
Pneumonia Vaccine Approximate Date*

MonthDayYear
Shingles Vaccine Approximate Date*

MonthDayYear
Tetanus Vaccine Approximate Date*

MonthDayYear
Flu Vaccine Approximate Date*

MonthDayYear
Other Providers

Please list all other doctors/specialists/providers who participate in your care
Primary Care Provider Name
Cardiologist (Heart) Provider Name
Dermatologist (Skin) Provider Name
Endocrinologist (Hormone) Provider Name
Gastroenterologist (Stomach) Provider Name
Pulmonologist (Lung) Provider Name
Nephrologist (Kidney) Provider Name
Neurologist (Nervous System) Provider Name
OB/GYN (Women's Health) Provider Name
Oncologist/Hematologist (Cancer) Provider Name
Orthopedic Doctor (Bone/Muscle) Provider Name
Otolaryngologist (Ear/Nose/Throat) Provider Name
Pain Management Provider Name
Physical Therapy Provider Name
Psychiatrist or Counselor Provider Name
Rheumatologist (Autoimmune) Provider Name
Social Worker/Case Worker Provider Name
Urologist (Kidney/Bladder) Provider Name
Other Provider Name
Social History
Please select which of the following applies to you

TobaccoSmokelessAlcoholDrugsMedical MarijuanaExercise
TOBACCO
Packs Per Day*
How Many Years?*
When Did You Quit?*
SMOKELESS
Uses Per Day*
How Many Years?*
When Did You Quit?*
ALCOHOL
Drinks Per Week*
Have You Undergone Treatment?*
When Did You Quit?*
DRUGS
Type*
Have You Undergone Treatment?*
When Did You Quit?*
MEDICAL MARIJUANA
Reason*
For How Long?*
EXERCISE
Type*
Frequency*
Occupation
Employment Type

Full TimePart TimeRetiredDisabled
Marital Status

SingleMarriedPartnerDivorcedWidowed
Should be Empty:

Patient Intake Form

Medical History

Medications

Allergies

Surgical History

Other Providers

Social History