Medical Patient Intake Form

Patient Intake Form
Section 1 - Patient Information
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Sex Assigned at Birth
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2 - Your Nicotine Use

We meet you where you are — whether you want to cut back or quit entirely.
1. What nicotine products do you currently use? (Select all that apply)
How much Nicotine do you use on a typical day?
How soon after waking do you use nicotine for the first time?
How long have you been using nicotine products?
What is your goal right now?
Have you tried to cut back or quit before?
7. If yes — what methods have you tried? (Select all that apply)
Did you experience any side effects from previous cessation medication? If yes, please describe.
Do you have a target quit or cut back date in mind?
Section 3 - Medical History

Your answers help our providers identify the safest and most effective treatment for you.
Have you ever had an allergic reaction to varenicline (Chantix) or bupropion (Zyban)? If so, which one?
Do you have a history of any of the following? (Select all that apply)
Have you been hospitalized or had a major illness in the past 3 months? If yes, please describe.
Are you currently pregnant, trying to become pregnant, or breastfeeding?
Section 4 - Mental Health & Wellbeing

These questions are standard safety screens — not a barrier to care. We're here to support you.
Do you have a current diagnosis of any of the following? (Select all that apply)

Other
Do you have a current diagnosis of any of the following? (Select all that apply)
Are you currently seeing a therapist, psychiatrist, or other mental health provider?
In the past month, have you experienced any of the following? (Select all that apply)
Have you ever had thoughts of suicide or self harm?
Section 5 - Sleep & Alcohol Use
Do you currently experience any of the following? (Select all that apply)
How often do you drink alcohol?
Have you ever blacked out, acted aggressively, or had unusual behavior while drinking?
Do you operate heavy machinery, drive professionally, or do safety-sensitive work?
Section 6 - Current Medications & Substances

Stopping smoking can change how your body processes certain medications. Full disclosure keeps you safe.
Please list all prescription medications you currently take:
Do you take any of the following? (Select all that apply)
Do you currently use any cannabis or any other recreational substances?
Do you have any known drug allergies? If yes, please list here:
Section 7 - Motivation & Support

Understanding what drives you helps us personalize your plan.
What is your main reason for wanting to quit or cut back now? (Select all that apply)
On a scale of 1-10, how confident are you that you can quit or cut back?
Does anyone in your household currently smoke or vape?
What type of support would be most helpful to you? (Select all that apply)
Section 8 - Consent & Acknowledgement
Date

MonthDayYear
Date
Signature
Should be Empty:

Patient Intake Form

Section 1 - Patient Information

Section 2 - Your Nicotine Use

Section 3 - Medical History

Section 4 - Mental Health & Wellbeing

Section 5 - Sleep & Alcohol Use

Section 6 - Current Medications & Substances

Section 7 - Motivation & Support

Section 8 - Consent & Acknowledgement