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.
HomeCell
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
MammogramPap SmearBone DensityColonoscopyEye ExamProstate ExamStress TestHearing TestFoot ExamEKG
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
PneumoniaShinglesTetanusFlu
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
TobaccoSmokelessAlcoholDrugsMedical MarijuanaExercise
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
Full TimePart TimeRetiredDisabled
SingleMarriedPartnerDivorcedWidowed
Should be Empty:

New Patient Intake Form

Your Information

Medical History

Medications

Allergies

Surgical History

Tests

Vaccines

Providers

Social History