Medical Intake form

Medical Intake form

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Name

First NameLast Name
Person Filling Out This Form (if not the Patient)

First NameLast Name
Relationship to the Patient
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Place of Birth
City/State or Town/Country if not in the US
Gender
Marital Status
Did something trigger your change in health?
Blood type

ABABORh+Rh-Unknown
Tuberculosis
When was the last time you had a test for Tuberculosis?

MonthDayYear
Date
What was the result?
Have you ever had a positive test for Tuberculosis?

YesUnsureNo
If yes, did you complete ≥6 months of preventative treatment?

YesNoUnsure
Are you experiencing any of the following symptoms?

cough >3 weeksunexplained weight losscoughing up blooddrenching night sweats
Have you had known contact with someone known to have TB disease?

YesNo
Vaccinations
Did you receive your childhood vaccinations?

YesNoUnknown

Have you had the tests below?

Have you ever been diagnosed with or tested positive for a sexually transmitted disease?

YesNo

Medical History
To your knowledge, have any of your blood relatives had any of the following section?

NoneUnknownYes

Family History

	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
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

Surgical History

Gastroenterology Related Medical History

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.

Immune System Related Medical History cont.

Lung Related Medical History

Cancer History

Cancer History Cont.

Mental Health Condition History

Please list any significant physical trauma you've experienced
Please list emotional trauma you've experienced in your life
Gynecological History
Gynecological History

Post partum depressionToxemiaGestational diabetesBaby over 8 pounds

Gynecological History cont.

Gynecological History cont.

Fibrocystic breastsEndrometriosisFibroidsInfertilityPainful periodsHeavy PeriodsPMDD
Menopausal patients

Hot flashesMood SwingsConcentration/Memory problemsVaginal drynessDecreased libidoHeadachesWeight gainLoss of control of urinePalpitationsDifficulty sleeping
Men's history

Prostate enlargementProstate infectionChange in libidoImpotenceDifficulty obtaining an erectionDifficulty maintaining an erectionFrequent urination at nightUrgency/Hesitancy/change in streamLoss of urine controlOther
Dental history

Silver Mercury fillingGold fillingsRoot canalsImplantsTooth painBleeding gumsGingivitisFloss regularly

Medication history

	Currently	Past use	Rarely used	Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives

Tuberculosis