Medical Intake form
Welcome to Barabara Taylor's in take form. Please answer all questions. It's long but worth it, so take your time. Because Plan "B" is Better!
1) Please enter full name
First Name
Last Name
2) Person Filling Out This Form (if not the Patient)
First Name
Last Name
3) Relationship to the Patient
4) Email
example@example.com
5) Phone Number
Format: (000) 000-0000.
6) Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
7) Date of Birth
-
Month
-
Day
Year
Date
8) Place of Birth
City/State or Town/Country if not in the US
9) Gender
Please Select
Male
Female
10) Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
11) Did something trigger your change in health recently?
12) Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Tuberculosis
13) When was the last time you had a test for Tuberculosis?
-
Month
-
Day
Year
Date
14) What was the result?
15) Have you ever had a positive test for Tuberculosis?
Yes
Unsure
No
16) If yes, did you complete (6) months of preventative treatment?
Yes
No
Unsure
17) Are you experiencing any of the following symptoms?
cough for 3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
18) Have you had known contact with someone known to have TB disease?
Yes
No
Vaccinations
19) Did you receive your childhood vaccinations?
Yes
No
Unknown
20) Do you have any of the following conditions?
Rows
Yes
No
Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Allergies
21) Do you have any allergies?
Yes
No
If yes, please list.
22) Do you have any drug allergies?
Yes
No
If yes, please list.
Sexual Health
23) What is your sexuality?
Bisexual
Gay
Heterosexual
Lesbian
Transexual
Other
24) Have you had the following tests below?
Rows
Yes
No
Unsure
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test
25) Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
Yes
No
26) If yes, please check all that apply
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis
Other
Medical History
27) To your knowledge, have any of your blood relatives had any of the following section?
None
Unknown
Yes
28) Family History
Rows
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
29) Surgical History
Rows
Yes
No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty
30) Gastroenterology Related Medical History
Rows
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
31) Cardiology Related Medical History
Rows
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
32) Endocrine Related Medical History
Rows
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
33) Nephrology Related Medical History cont.
Rows
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
34) Orthopedics Related Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
35) Immune System Related Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
36) Lung Related Medical History
Rows
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
37) Cancer History
Rows
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
38) Cancer History Cont.
Rows
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Medical Health
39) Mental Health Condition History
Rows
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
40) Please list any significant physical trauma you've experienced
41) Please list emotional trauma you've experienced in your life
Gynecological History
42) Gynecological History
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
43) Gynecological History cont.
Rows
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
44) Gynecological History cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
45) Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
46) Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
47) Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
48) Medication history
Rows
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
49) Medications
50) Supplements
Signature: My signature completes this application. All information above is deemed true and correct to the best of my ability. This also confirms Ms. Barbara Regeana Taylor in association with, and owner of The Plan "B" is Better Health Program is to receive any and all payments from me as "Client / Patient" due as part of home daily living services thus provided from Ms. Barbara Regeana Taylor for services such as daily living activities and active service for the above patient.
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