Advocacy intake form

Advocacy Intake Form
Patient Name*

LastFirstMI
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Age
Phone Number*
Home
Sex*

FemaleMale
Email*
example@example.com
Ethnicity
In Case of Emergency:*
Name
Relationship
Emergency contact Phone
How did you find us?
What are the advocacy concerns would you like the doctor to address at THIS visit?
What is your preferred pharmacy? Please include the address
What are your past medical problem? Please List:
Current Medications (vitamins, birth control pills):*
Allergies to medicines, foods, etc.*
What medical problems run in your family? Please List:*
Social History:
Tobacco use: YES/NO
If yes, how many pack per day?
If no, have you smoked in the past?
How many pack per day?
Alcoholic Use: Do you drink more than one alcoholic beverage a week? YES/NO
If yes, how often?
What do you drink?
Examinations:

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

MonthDayYear
Date of last colonoscopy if applicable

MonthDayYear
Date of last mammogram if applicable

MonthDayYear
Include other comments regarding your Medical History
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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Acute Telemedicine visit- 30 minutes
$100.00 Quantity

Total

$0.00

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Advocacy Intake Form