Concierge Medical Patient Intake Form

Concierge Patient Intake Form
Patient Name*

LastFirstMI
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Home
Cellular
Birthdate*

MonthDayYear
Date
Age
Sex*

FemaleMale
Email*
example@example.com
Race
Choose One

MarriedSingleDivorcedWidow
Employment Information:
Patient's Employer
Occupation
Work Phone No.
Ext.
In Case of Emergency:
Name
Relationship
Phone
Referred by
Do you currently have any medical concerns? Please List:
Past History: (Please check if you have had any of the following):

High blood pressureBirth defects or abnormalitiesHeart AttackKidney diseaseStrokeInfluenzaHigh CholesterolAnemiaDepressionLeg swellingCongestive Heart FailureBlood clotThyroidIrregular heartbeatAcid RefluxArthritisLiver diseaseUlcersPneumoniaDementiaVision problemHearing problem
Cancer, Type:
Surgeries (dates):
Other Diseases:
Current Medications (vitamins, birth control pills):*
Allergies to medicines, foods, etc.*
Family History:
Father: Health
Age
Deceased
At age
Cause
Mother: Health
Age
Deceased
At Age
Cause
# of siblings
# living
# deceased
Cause
Social History:
Tobacco use: YES/NO
If yes, how many pack per day?
How many years?
If no, have you smoked in the past?
How many pack per day?
How many years?
Alcoholic Use: Do you drink more than one alcoholic beverage a week? YES/NO
If yes, how often?
What do you drink?
Family Diseases: Check diseases known in your blood relatives (not yourself)

High blood pressureAllergyHeart troubleAnemiaMigraineBleeding (abnormal)DropsyEpilepsyStrokesCancerDiabetesNervous breakdownKidney diseaseSyphilis or (bad blood)SuicideObesityArthritisRheumaticFever
Other:
Examinations:

MonthDayYear
Date of last physical examination
Reason
Hospitalizations
Dates
Reason
Date of last pap

MonthDayYear
Date of last colonoscopy

MonthDayYear
Date of last mammogram

MonthDayYear
Do you now have or have had any of the following?

Joint painsMuscle achesArthritisLimitation of motionBackacheLeg painsPain or stiffness (neck)GoiterAsthmaLung diseaseRaise sputumEmphysema BronchitisHeart troubleHigh blood pressureShortness of breathPalpitation or flutteringChest painTire easilySwelling of anklesIndigestionNausea or vomitingAbdominal painDiarrheaColitis JaundiceHemorrhoids (piles)Bleeding or black stoolsKidney diseaseKidney stonesPainful urinationPus or blood in urineDribbling of urineNervousness or anxietyTrouble sleepingHeadachesBored or depressedNervous breakdownFaintingConvulsionsNeuritis or NeuralgiaParalysis
Menstrual History:
Menstruation began at age
28 day cycle?
If no, how many days?
Duration of bleeding
Pain with periods?
Amount of flow:
Light
Med.
Heavy
Date of 1st day of last

MonthDayYear
Menstrual period

MonthDayYear
Bleeding between periods
Bleeding after intercourse
Irritation or discharge
Itching or burning
Are you on birth control? (method)
Include other comments regarding your Medical History
Are you aware and agreeable to monthly fee of $200/month or $2000/year*
Preferred Consultation Time
All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician/staff/volunteers, I accept full liability from any consequences arising there from.
Signature*

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Date*

MonthDayYear
Patient's Name Printed*

First NameLast Name

Payment

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Concierge Patient Intake Form