Patient Intake Questionnaire
Let's get to know you for a Care Plan (10min)
Name:
*
First Name
Last Name
DOB:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Primary Care Info:
*
Height:
*
Please Select
Weight:
*
Please Select
Have you had your yearly physical?
*
Yes
No
Are you Diabetic? (If no, Skip to Pharmacy Info Section)
*
Yes
No
If yes, Which type?
Type 1
Type 2
If diabetic, Have you recently experienced a hypo or hyperglycemic episode?
Yes
No
How many times do you check your blood sugar daily?
What were your last 3 blood sugar readings? (>50 or <300+)
example@example.com
Do you inject insulin?
Yes
No
If yes, How many times per day?
How many times per day do you inject?
What other health conditions do you have?
Pharmacy Infomation
*
Do you have trouble consistently taking your medications?
*
Yes
No
Do you have difficulty remembering things?
*
Yes
No
Do you reside in a nursing care or use Assisted living?
*
Yes
No
Do you need assistance with everyday activities?
*
Yes
No
If yes, Who assists you daily?
Do you consider your living environment safe?
*
Yes
No
How would you describe your vision?
*
Please Select
Excellent
Very Good
Good
Fair
Poor
Very Poor
Do you wear glasses?
Type option 1
Type option 2
Type option 3
Type option 4
How would you describe your hearing?
*
Please Select
Excellent
Very Good
Good
Fair
Poor
Very Poor
Do you struggle with alcohol use?
*
Yes
No
Do you currently or have you ever smoked or used nicotine products?
*
Yes
No
Do you have any dental concerns or issues?
*
Yes
No
If yes, could you give details?
Do you wear dentures?
Yes
No
Are you currently on a specific diet routine?
*
Yes
No
How may days of the week do you perform physical activity?
*
Please Select
Less than 1
1
2
3
4
5
6
All 7
Have you had any falls in the past 6 months?
*
Yes
No
Have you been hospitalized, gone to the ER, or had any major surgeries within the past 6 months?
*
Yes
No
Do you have access to Wi/Fi/computer/smartphone?
Yes
No
Do you consent to receiving a text message to notify you of your upcoming monthly call?
*
Yes
No
Are you interested in new monitoring technology such as our Smart Pillbox?
*
Yes
No
Emergency Contact Info (optional):
Anything else we missed?:
-- Employee Mobile Section --
Submit
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