New Patient Intake Form

New Patient Intake Form
Name

First NameLast Name
Preferred name
Pronouns
Sex assigned at birth
Gender
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Insurance Company
Insurance member ID
Subscriber (include name, DOB and relationship to subscriber if you are not the the. subscriber)
What brings you in today? List your health concern(s)
Do you give Dr. Nicole Kearney to discuss your health information with your health care providers if necessary?

yesno
Tell me what a typical breakfast, lunch and dinner looks like. Do you avoid any foods or food groups?
Do you use tobacco products

yesno
How many alcoholic beverages do you have /week?
Recreational drug use
Please share pertinent family medical history (mom, dad, siblings, grandparents)
How many days/ week do you exercise? What type of exercise?
What are your hobbies/ what brings you joy?
Health History
Hospitalizations/ surgeries or pertinent medical diagnoses with dates
Allergies
Please list all medications and supplements with dosing
Do you suffer from any of the following health conditions/symptoms

FatigueWeight gainWeight lossTrouble sleepingHeadaches/ migrainesVertigo/ dizzinessDifficulty concentratingAllergiesAsthmaEczemaChest painHeart palpitationsHigh blood pressureSkin rashes/ concernsJoint painDiarrheaConstipationAbdominal painGas/ bloatingAcid refluxNauseaAnxietyDepressionThyroid issues
Gynecologic History
Check if you experience any of the following

Heavy periodsPainful periodsIrregular periodsPMSFibroidsEndometriosisPCOSHistory of abnormal papsHistory of infectionsHistory of bacterial vaginosisInfertility
How long are your cycles (from your first day of bleeding to the last day before your next period)
Birth control
Should be Empty:

New Patient Intake Form

Health History

Gynecologic History