New Patient Intake Form

New Patient Intake Form
Your Information
Name
Date of Birth

MonthDayYear
Age
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Please contact by
Address
City
State
Zip
Gender
Pharmacy Name
City
Insurance
Previous Provider Doctor
Medical History

Conditions

Rows	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

Rows	Medication	Dose	Fequency
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7

Allergies

Drug Allergies

Rows	Drug Allergy	Reaction
Allergy #1
Allergy #2
Allergy #3
Allergy #4

Non-Drug Allergies

Rows	Non-Drug Allergy	Reaction
Allergy #1
Allergy #2
Allergy #3
Allergy #4

Surgical History

Rows	Procedure	Approximate Date
Surgery #1
Surgery #2
Surgery #3
Surgery #4

Tests
Tests
Mammogram Approximate Date

MonthDayYear
Mammogram Facility/Provider
Pap Smear Approximate Date

MonthDayYear
Pap Smear Facility/Provider
Bone Density Approximate Date

MonthDayYear
Bone Density Facility/Provider
Colonoscopy Approximate Date

MonthDayYear
Colonoscopy Facility/Provider
Eye Exam Approximate Date

MonthDayYear
Eye Exam Facility/Provider
Prostate Exam Approximate Date

MonthDayYear
Prostate Exam Facility/Provider
Stress Test Approximate Date

MonthDayYear
Stress Test Facility/Provider
Hearing Test Approximate Date

MonthDayYear
Hearing Test Facility/Provider
Foot Exam Approximate Date

MonthDayYear
Foot Exam Facility/Provider
EKG Approximate Date

MonthDayYear
EKG Facility/Provider
Vaccines
Vaccines
Pneumonia Vaccine Approximate Date

MonthDayYear
Shingles Vaccine Approximate Date

MonthDayYear
Tetanus Vaccine Approximate Date

MonthDayYear
Flu Vaccine Approximate Date

MonthDayYear
Providers

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
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
Marital Status
Should be Empty:

New Patient Intake Form

Your Information

Medical History

Medications

Allergies

Surgical History

Tests

Vaccines

Providers

Social History