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:
Pharmacy Information
Vitals
*
Have you had your yearly physical?
*
Yes
No
Diabetic Section
What other health conditions do you have?
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
Do you consider your living environment safe?
*
Yes
No
Vision
Hearing
Do you struggle with alcohol use?
*
Yes
No
Do you currently or have you ever smoked or used nicotine products?
*
Yes
No
Dental
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
Falls
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 Section ----------------
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