Patient Medical Intake Form

2603 Oak Lawn Ave Suite 101 Dallas TX 75219
Ph. (214) 219-4100 www.deNovoHC.com
Todays Date

Month Day Year
Patient Information
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
How do you prefer to be called?
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Cell Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Patient E-Mail *
How would you like us to communicate detailed medical information? *
Current Occupation *
Emergency Contact *
Relationship to Patient *
Emergency Contact Best Phone Number *

Area Code Phone Number
Present Health
Please describe your present health goals. *
Are you currently under the care of a family physician or any other health professional? If yes, include details. *
Patient Medications

Be sure to include all medications,including prescriptions, over-the-counter, dietary supplements and vitamins.

Please List All Medications

Medication Name

Dosage Amount

#Taken Daily

Ordering Doctor

Start Date

Any Drug/Medication Allergies? *

Yes No Unknown
List Drug/Medication Allergies & Reactions:

Name of Medication / Allergic Reaction 0/300
*I understand that my practitioner relies on the medication information I provide to him/her for my care and that any medication misinformation can result in hospitalization or death. I also understand that prevention of dangerous drug interactions and duplications of medications are a top priority for my safety. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete and I give permission for the facility to review my medication history.
Name *

First Name Last Name
Past Medical History
Please list any medical conditions, surgeries and hospitalizations along with dates.
Adult Imminizations/Vaccinations:
MMR Booster (1957+Up)

Month Day Year
Date
Influenza (yrly)

Month Day Year
Date
Tetanus (E10yrs)

Month Day Year
Date
Shingles (50+)

Month Day Year
Date
Pneumonia (65+)

Month Day Year
Date
HPV (

Month Day Year
Date
Health as a child: *
Have you ever experienced a reaction to vaccination(s)? If yes, please specify. *
Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage: *

Yes, I Smoke Daily Yes, Sometimes I Smoke No, I Quit Smoking No, I Never Smoked
# Cigarettes per day? *
Date I Quit Smoking: *

Month Day Year
Total Years Smoking
Alcohol Consumption *

I don't drink 1-4 drinks/month 1-2 drinks/day 3-4 drinks/day 5+ drinks/day
Caffeine Consumption *

I don't use caffeine 1-4 cups/month 1-2 cups/day 3-4 cups/day 5+ cups/day
How many times in the past year have you had 5 or more drinks in a day for men or 4 or more drinks in a day for women or any adult older than 65?

0 1 2 3-5 5-10 10-20 More than 20
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition and help you reach your goals)? *
Family History
Is there a family history of the health problem(s) listed above? If yes, please specify. *

Fill in as appropriate

Child

Myself

Father

Mother

Brother(s)

Sister(s)

Spouse

Other

Age (if living)

Age (at death)

Cause of death

Anemia

Cancer

Diabetes

Epilepsy

Glaucoma

Heart Disease

High Blood Pressure

Hay Fever

Hives

Kidney disease

Mental illness

Rheumatoid arthritis

Tuberculosis

Syphilis

Stroke

Other

Any other family illnesses or concerns? If yes, please specify. *
Daily Routine
What time do you usually go to bed?
What time do you usually awaken?
Do you often take naps during the day?

Yes No
How do you generally feel when you wake up in the morning? *
How would you describe your experience of sleep? *
Do you snore or does your sleep partner report that you do?
How regularly do you follow your ideal routine (i.e., go to bed early, eat meals on time, exercise regularly)? *
How would you rate your usual energy level? *
Do you travel often?

Yes No
Excercise
How often do you excercise? *
What type of exercise do you do?
How long do you excercise each time?
Rate the intensity of your excercise.
Eating Habits

Choose the answer that best describes your eating habits *

Daily

Weekly

Monthly

Never

Grains/cereals

Vegetables

Fruits

Dairy

Eggs

Poultry

Meat (beef, pork, etc.)

Seafood

Sugar/Honey

Desserts

Juices

Describe what you typically eat
Breakfast
Lunch
Dinner
Snack
Do you eat between meals?

Yes No
Do you eat meals at regular times?

Yes No
Which is your biggest meal? *
How much water do you drink per day? *
Rate your digestion. *
Describe Bowel frequency
Bowel nature
Bowel movement associated with (choose those that apply).

Pain Blood Mucous Foul Smell
Do you take the following?

Probiotics Additional Dietary Fiber Laxatives
Miscellaneous
Do you experience any of the following? *

Depression Anxiety Fear or panic Loneliness Worry High stress level Anger Lack of memory Light-Headedness Lack of energy Suicidal thoughts or attempts Irritation
Social History
Marital Status
Highest Education
Is spirituality important to you?

Yes No
Do you have financial concerns?

Yes No

Select the best answer for the the questions asked. *

Excellent

Good

Fair

Poor

How are your family relationships?

How is your social life?

How is your mental health?

How is your career?

How purposeful is your life?

Rate your spiritual life.

As a child did you experience any abuse or trauma?

Yes No
If yes, type of abuse?
Are you Sexually Active?

Yes No
Sexually Active with

One partner More than one partner Same Sex partner
Are you satisfied with your sexual relationship(s)?

Yes No
For Men Only
Please indicate which of the following areas are troublesome (if any).

Hernias Sexual difficulty Urination Erection problem Libido Birth control Prostrate problems Discharge or sores Venereal disease Testicular masses
For Women Only
Date of last Mammogram
Date of last PAP
Age at onset of menses:
Which of the following describes your menstruation?
How many days does your menstrual period last?

1-4 days 5-7 days More than 1 week Irregular throughout the month
How is your menstrual flow?
Do you have any associated symptoms before or during menstruation?

None Pain Fluid retention Migraine Depression Acne Tension Nightmares Frustration Loneliness
Do you have any discharge outside of your menstrual period?

Yes No
Do you ever experience pain during intercourse?

Yes No
Are you pregnant now?

Yes No I don't know
Do you have any sexual difficulties?

Yes No
Do you take contraceptive pills or use other forms of birth control?

Yes No
If yes, please explain.
Number of previous pregnancies.
How many children do you have?
How old are your children?
Do you have any history of abortion, miscarriage, or problems related to pregnancy or labor? If yes, explain.
Do you breast self-exam regularly?

Yes No
Do you experience any of the following symptoms with your breasts?

Pain or tenderness Lumps Nipple discharge
Other comments
The answers I have provided are true, accurate and complete to the best of my knowledge.
Signature
Should be Empty:

Patient Information

Present Health

Patient Medications

Past Medical History

Adult Imminizations/Vaccinations:

Patient Tobacco/Alcohol/Caffeine Usage

Family History

Daily Routine

Excercise

Eating Habits

Describe what you typically eat

Miscellaneous

Social History

For Men Only

For Women Only