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Patient Intake Form
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Street Address
City
State
ZIP Code
Home Phone
Mobile Phone
Social Security Number
E-mail
Ethnicity/Race
Weight
Height
Primary Language
English
Spanish
Other
Marital Status
Single
Married
Divorced
Separated
Widowed
Spouse Name
Spouse Phone
Emergency Contact Name
Relationship
Home Phone
Mobile Phone
E-mail
Primary Insurance Company
Group #
ID #
Primary Insurance Type
HMO
PPO
Medicare
Other
If not policyholder, relation
Spouse
Child
Parent
Other
Policyholder Name
Policyholder Date of Birth
Policyholder SSN
Secondary Insurance Company
Group #
ID #
Secondary Insurance Type
HMO
PPO
Medicare
Other
If not policyholder, relation
Spouse
Child
Parent
Other
Policyholder Name
Policyholder Date of Birth
Policyholder SSN
Primary Care Physician
Primary Care Phone
Other Physician Name 1
Specialty 1
Other Physician Name 2
Specialty 2
Other Physician Name 3
Specialty 3
Other Physician Name 4
Specialty 4
Allergy 1
Reaction 1
Allergy 2
Reaction 2
Allergy 3
Reaction 3
Allergy 4
Reaction 4
Medication 1
Dose 1
Medication 2
Dose 2
Medication 3
Dose 3
Medication 4
Dose 4
Mother: Major Conditions/Illnesses
Mother Living?
Yes
No
If deceased, age
Father: Major Conditions/Illnesses
Father Living?
Yes
No
If deceased, age
Sibling: Major Conditions/Illnesses
Sibling Living?
Yes
No
If deceased, age
Other Relative 1: Conditions/Illnesses
Other Relative 1 Living?
Yes
No
If deceased, age
Other Relative 2: Conditions/Illnesses
Other Relative 2: Conditions/Illnesses
Yes
No
If deceased, age
Surgery/Illness 1: Description
Doctor 1
Location 1
Year 1
Surgery/Illness 2: Description
Doctor 2
Location 2
Year 2
Surgery/Illness 3: Description
Doctor 3
Location 3
Year 3
Surgery/Illness 4: Description
Doctor 4
Location 4
Year 4
Have you ever had any of the following?
Anemia
Arthritis
Asthma
Atrial Fibrillation
Bleeding Problems
Benign Prostatic Hyperplasia
Coronary Artery Disease
Cancer
Cardiac Arrest
Celiac Disease
Chest Pain
Congestive Heart Failure
Chronic Fatigue Syndrome
Depression
Diabetes
Drug/Alcohol Abuse
Erectile Dysfunction
Fibromyalgia
GERD
Heart Disease
Hyperinsulinemia
Hyperlipidemia
Hypertension
Hypothyroidism
Infection Problems
Insomnia
Irritable Bowel Syndrome
Kidney Problems
Menopause
Migraines/Headaches
Neuropathy
Onychomycosis
Organ Injury
Osteoporosis
Pulmonary Embolism
Seizure Disorders
Shortness of Breath
Sinus Conditions
Stroke
Syndrome X
Tremors
Wheat Allergy
Other medical problems
What's your primary health concern?
Approximately when did this issue begin?
Does the issue cause you pain?
Yes
No
If so, where?
How has the pain changed since it began?
Increased
Decreased
Unchanged
How quickly did your current pain begin?
Gradually
Suddenly
How often does your pain occur?
Constantly
Occasionally
Rarely
When is your pain at its worst?
Morning
Afternoon
Evening
Night
What are your current symptoms?
Describe your pain
Aching
Numbness
Spasming
Throbbing
Cramping
Shock-like
Squeezing
Tingling
Dull
Shooting
Stabbing/Sharp
Tiring/Exhausting
Hot/Burning
Any other health concerns we should know about?
Do you currently consume alcohol?
Yes
No
How many drinks per week?
Do you currently smoke?
Yes
No
What do you smoke?
Tobacco
Marijuana
Other
How many cigarettes per day?
Do you currently use any other drugs?
Yes
No
What other drugs do you take?
How often?
Daily
Weekly
Occasionally
Rarely
Do you drink caffeine?
Yes
No
How many cups per day?
Are you sexually active?
Yes
No
Would you like to be checked for STIs?
Yes
No
How frequently do you exercise?
Daily
Weekly
Occasionally
Rarely
Are you on a special diet?
Yes
No
What diet?
Are you planning a pregnancy?
Yes
No
Are you pregnant now?
Yes
No
What type of contraception do you currently use?
When was your last menstrual cycle?
Pharmacy Name
Street Address
City
State
ZIP Code
Phone
By signing below, I hereby acknowledge, agree, and authorize all of the following:
By signing below, I hereby acknowledge, agree, and authorize all of the following: a) Accurate Information. I certify that the information provided on this form is accurate, complete, and up to date to the best of my knowledge.
b) Patient Rights and Responsibilities. I understand that the healthcare facility maintains a Notice of Privacy Practices, which describes how my protected health information may be used and disclosed, and how I may access my health records. I understand that I have the right to review this healthcare facility’s Notice of Privacy Practices prior to signing this form.
c) Release of Medical Information. I authorize the release of my health information to the healthcare facility in accordance with the healthcare facility’s Notice of Privacy Practices. This includes, but is not limited to, releasing medical information to my referring physician, primary care physician, and any physician(s) I may be referred to. The healthcare facility shall ensure all health information remains confidential, as required by HIPAA, and will not release any of my health information without my consent.
d) Consent for Treatment. I grant the healthcare facility, including its affiliated providers, physicians, and other medical personnel, permission to use the health information provided for the purpose of my medical treatment as necessary.
e) Consent to Communication. I consent to receiving communications from the healthcare facility regarding appointment reminders, test results, and other necessary healthcare-related information via phone, email, or channels.
f) Acknowledgment. By signing below, I hereby acknowledge, agree, and authorize all of the above, and I authorize the healthcare facility to retrieve and review my medical history and authorize the healthcare facility to release the information required in obtaining procedure authorization or the processing of any insurance claims.
Patient Signature (type full name)
Print Name
Date
Finish & Submit
