True Essence Health and Wellness
New Patient Intake Form
Full Name
First Name
Last Name
What is date of birth?
MM/DD/YYYY
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name, relationship, phone number
Primary Care Provider (if any)
Name/Clinic with last visit date
Insurance Information
Insurance Plan and Member ID
Self-Pay Patient
Please Select
Yes
No
Check the conditions that apply to you:
Asthma
Cancer
Heart disease
Kidney disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Thyroid disorder
High cholesterol
COPD
Depression/Anxiety
Stroke
Other
Surgical history
Year if known
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Reason for Visit
Submit
Should be Empty: