• New patient Intake form

    Collin County Physicians

  • Completing and submitting this form is required before being able to see the doctor.

    We understand filling forms can be time consuming and appear tedious. However, this is essential for a smooth workflow for all of us and the information you provide could be very vital for your diagnosis and treatment plan. We thank you for your patience. Estimated completion time: 20 minutes
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I agree to provide a valid and unexpired credit or debit card prior to receiving any services.*
  • I provide consent to let Knowledge Internal Medicine PLLC doing business as Collin County Physicians use my card on file to charge for any portion of my current or future visits (Patient Responsibility) that is not covered by my insurance company.*
  • Afterhours and weekend visits costs extra. The usual cost of afterhours and weekend visits starts at 350 dollars and maybe higher depending on your reason for visit. If you have not met your deductible, this will be your responsibility. Do you understand and agree to this?
  • Do you consent to receiving text messages on your phone about your appointments, test results, refills and other information related to your health?(please review our privacy policy for details)*
  • Do you consent to receiving emails about your appointments, test results, refills and other information related to your health? (please review our privacy policy for details)*
  • Do you have health insurance*
  • Insurance details*
  • Reason for visit?*
  • Past medical history*
  • Past Surgical history*
  • Do you see any other doctors for any health conditions?*
  • Name and specialty(for example: cardiology or nephrology) of the the other doctors involved in your health. Use the ADD ROW button to add more names
  • Do you have any allergies?*
  • Are you currently taking any prescription medications?*
  • Family history (write adopted, none or unknown in the other field if applicable)*
    Rows
  • Do you smoke cigarettes or have you ever smoked?*
  • Do you drink alcohol more than once a week on average?*
  • Do you use any drugs? ( example: heroin, cocaine, meth, fentanyl etc.)*
  • Did you receive your routine vaccinations?
  • Vaccine history
    Rows
  • Health prevention
    Rows

  • Review of organ systems ( head to toe symptom checker)

    Please check any symptoms you are currently experiencing
  • General health/constitutional symptoms*
  • HENT ( Head, Ears, Nose, Throat)*
  • Eyes/Vision*
  • Neck*
  • Heart/Cardiovascular*
  • Lungs/Respiratory*
  • Digestive system/Gastrointestinal*
  • Kidney/Urologic*
  • Genital*
  • Blood/Hematologic/cancer*
  • Brain/Neurologic*
  • Joints/Musculo-skeletal*
  • Skin/Dermatologic*
  • Psychiatric*
  • Endocrine*
  • What is your height and weight?*
    Rows

  • Sexual Health

  • What is your sexuality?
  • Pregnancy history
    Rows
  • Any pregnancy related complications ( example: preeclampsia, gestational diabetes)
  • Have you ever had an abnormal Pap smear?
  • Gynecological History
    Rows
  • Gynecological History cont.
  • Menopausal patients
  • Men's history
  • Should be Empty: