Clone of Concierge Services Intake Medical History Form

ALMS Community Health Center Intake Medical History Form

Please complete the medical history questions extracted from the source document. All fields are optional unless otherwise indicated.
Patient Information
Patient Name

First NameMiddle NameLast Name
Drivers License Front
Drivers License Back
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Visit Information
Date of Visit request or confirmed for Monday, Tuesday, Wednesday and Fridays only.
Date of Visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Today's Visit / Chief Complaint
History of Present Illness
Chief complaint
Describe your main concern
When did this problem start?
Onset
Location
Duration
Severity
What makes it better or worse?
What treatments or medications have you tried?
Additional details about this problem
Medical History
Past medical history: Diabetes
Past medical history: Hypertension
Past medical history: Heart disease
Past medical history: Asthma
Past medical history: Cancer
Surgical history: Procedure name
Surgical history: Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current medication: Name
Current medication: Dose
Current medication: Frequency
Allergies

Other
Allergy details
Family history: Diabetes
Family history: Hypertension
Family history: Heart disease
Family history: Cancer
Family history: Stroke
Other medical history notes
Social History and Lifestyle
Tobacco Use
Alcohol Use
Recreational Drug Use
Marital Status
Living Situation
Children
Occupation
Exercise Frequency
Average Exercise Duration (minutes per session)
Additional Social History Notes
Are you self pay or do you have insurance
If you do not have insurance, please identify a second form of ID and take a picture You can take a picture of your Drivers License again if no other ID is available). List the name of the second ID (Drivers License, State ID, Library Card, etc...). Please enter NA (if Not Applicable)
Insurance Card Front
Insurance Card Back
Review of Systems
Constitutional Symptoms

Other
Eyes

Other
Ears, Nose, and Throat

Other
Cardiovascular

Other
Respiratory

Other
Gastrointestinal

Other
Genitourinary

Other
Musculoskeletal

Other
Skin

Other
Neurologic

Other
Psychiatric

Other
Endocrine

Other
Hematologic / Lymphatic

Other
Allergic / Immunologic

Other
Breasts

Other
Head

Other
Neck

Other
Back

Other
Extremities

Other
Other Symptoms

Other
Should be Empty:

ALMS Community Health Center Intake Medical History Form

Patient Information

Emergency Contact

Visit Information

History of Present Illness

Medical History

Social History and Lifestyle

Review of Systems