Medical Intake form

Today's Date*

Date

Name*

First NameLast Name

Person Filling Out This Form (if not the Patient)

First NameLast Name

Relationship to the Patient

Email*

example@example.com

Cell Phone*

Home Phone

Work Phone

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Place of Birth*

City/State or Town/Country if not in the US

Gender*

If you selected "Other", please specify

Sex Assigned at Birth*

Marital Status*

Preferred Pronouns*

If you selected "Other", please specify

Race / Ethnicity*

If you selected "Other", please specify

Preferred Language*

If you selected "Other", please specify

Upload Picture Of Issued State ID/ Drivers License *

Insurance Name*

Member ID*

Group ID*

Upload Picture Of Insurance Front and back*

Name*

First NameLast Name

MI

Phone Number*

Please enter a valid phone number.

Relationship To Patient*

Do you give us permission to discuss your health information with this person?*

YESNO

If you selected "No", please specify

How did you hear about us?*

GoogleOur WebsiteZocDocOther

If you selected "Other", please specify

Smoking Status (Tobacco):*

YesNo

How many packs per day?

When did you quit?

Date

Are you interest in Smoking Cessations*

YesNo

Alcohol Use:*

Caffeine: How Many Cups Per Day?*

Exercise: How many times a week?*

Do you have any pet?*

YesNo

If YES, what kind of pets?

Employment Status:*

If you selected Other, please specify

What is/was your occupation?*

Do you do any recreational drugs?*

YesNo

If YES, please list them:

Are you sexually active?*

YesNo

If YES, are you active with men, women, or both?

Any history of physical or domestic abuse/violence?*

YesNo

Father's History*

AliveDeceased

Age*

Please list any know health issues:*

Mother's History*

AliveDeceased

Age*

Please list any know health issues:*

Siblings: # of Brother(s)*

Siblings: # of Sister(s)*

Please list any know health issues:*

Children: # of Male(s)*

Children: # of Female(s)*

Please list any know health issues:*

Medications:*

Rows	Medications:
1
2
3
4
5
6
7
8
9
10

Pharmacy Name*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies*

Rows	Medication/Food	Reaction
1
2
3
4
5
6
7
8
9
10

When was your last?*

Rows	Date
1. Colonoscopy:
2. Stress Test:
3. EKG:
4. DXA Scan (bone density):
5. Flu Vaccine:
6. Covid Vaccine:
7. Pneumonia Vaccine:
8. Shingles Vaccine:

*Females Only*: When was your last?

Rows	Date
1. PAP Smear:
2. Mammogram:
3. Last Period Date:

How many TOTAL pregnancies have you had? (include miscarriages, abortions, etc)

Release of Information*

Signature*

Date*

Date

Signature*

Date*

Date

Signature*

Date*

Date

CONSENT FOR TREATMENT: By signing this document, I hereby request and authorize Lanham Internal Medicine Associates practices and providers including physicians, technicians, nurses, and other qualified personnel to perform evaluation and treatment services and procedures as may be necessary following the judgment of the attending medical practitioner(s). I acknowledge that no guarantee can be made by anyone concerning the results of treatments, examinations, or procedures.

PAYMENT GUARANTEE: I hereby guarantee payment of all charges related to all services, including motor vehicle accident (MVA), workman’s compensation (WC), and durable goods provided to me through Lanham Internal Medicine Associates from my first day of examination or treatment. I agree to make full payment to Lanham Internal Medicine Associates. If I fail to make full payment or comply with other payment arrangements made to Lanham Internal Medicine Associates approval, I understand that appropriate collection measures will be taken.

ELECTRONIC HEALTH RECORD: Healthcare providers require access to patient medical information whenever a patient presents for care to assure patient confidentiality. Lanham Internal Medicine Associates has an electronic medical record system that can share information about patient care provided in the hospital, or outpatient office. Additional records including those reflecting treatment for HIV/AIDS, drug or alcohol problems, and behavioral health issues, are maintained per relevant governmental and regulatory standards. Patient care summaries are automatically sent to designated Lanham Internal Medicine Associates other referring physicians, and to physicians who are consulted by the attending physician for coordination of care. Lanham Internal Medicine Associates can furnish and release medical records to federal and state healthcare oversight agencies upon written request.

ELECTRONIC PRESCRIBING: I understand that Lanham Internal Medicine Associates may use an electronic prescription system that allows prescriptions and related information to be electronically sent to the pharmacy. I have been informed and understand that Lanham Internal Medicine Associates providers using electronic prescribing systems will be able to see information about medications I am already taking, including those prescribed by other providers. I consent to Lanham Internal Medicine Associates and their providers to see this health information.

RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES: I have been made aware and understand that Lanham Internal Medicine Associates provides no facilities for the safekeeping of valuables. I hereby release Lanham Internal Medicine Associates from any responsibility due to the loss or damage of any valuables that I, or anyone accompanying me, may bring to the Lanham Internal Medicine Associates medical office.

Patients Name*

First NameLast Name

DOB*

Date

Signature of patient / Legal Guardian / Authorized representative: *

Relationship to patient (if not self):

New Patient Intake form

Insurance Information

EMERGENCY CONTACT INFORMATION

Patient History

Family History

PREFERRED PHARMACY INFORMATION

YOUR COPAY IS DUE AT THE TIME OF SERVICE. THANK YOU!