PATIENT INTAKE
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Have you recently been to the ER or discharged from the hospital?
Yes
No
What is the reason for your visit today?
Annual Exam
Health Concern
What is your primary health concern?
Approximately when did this issue begin?
Does this issue cause you pain?
Yes *please specify Pain Location
No
Pain Location
Please answer the following questions if applicable
How has the pain changed since it began?
Increased
Decreased
Unchanged
How often does your pain occur?
Constantly
Occaisonally
Rarely
When is your pain at its worst?
Morning
Afternoon
Evening
Night
Check any of the following that describe your pain:
Aching
Numbness
Spasming
Throbbing
Cramping
Shock-like
Squeezing
Tingling
Dull
Shooting
Stabbing/Sharp
Tiring/Exhausting
Hot/Burning
What are your current symptoms
List any other health concerns that you would like us to know about
MEDICAL HISTORY
Have you ever had any of the following?
Anemia
Yes
No
Arthritis Conditions
Yes
No
Asthma
Yes
No
Atrial Fibrillation
Yes
No
Benign Prostatic Hyperplasia
Yes
No
Bleeding Problems
Yes
No
Cancer
Yes
No
Cardiac Arrest
Yes
No
Celiac Disease
Yes
No
Chest Pain
Yes
No
Chronic Fatigue Syndrome
Yes
No
Congestive Heart Failure
Yes
No
Coronary Artery Disease
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Drug/Alcohol Abuse
Yes
No
Erectile Dysfunction
Yes
No
Fibromyalgia
Yes
No
Gerd
Yes
No
Heart Disease
Yes
No
Hyperinsulinemia
Yes
No
Hyperlipidemia
Yes
No
Hypertension
Yes
No
Infection Problems
Yes
No
Insomnia
Yes
No
Irritable Bowel Syndrome
Yes
No
Kidney Problems
Yes
No
Menopause
Yes
No
Migraines/Headaches
Yes
No
Miscarriage
Yes
No
Neuropathy
Yes
No
Onychomycosis
Yes
No
Organ Injury
Yes
No
Osteoporosis
Yes
No
Pulmonary Embolism
Yes
No
Seizure Disorders
Yes
No
Shortness of breath
Yes
No
Sinus Conditions
Yes
No
Stroke
Yes
No
Syncope
Yes
No
Thyroid Disorder
Yes
No
Tremors
Yes
No
Wheat Allergy
Yes
No
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TREATING PHYSICIANS
Previous Primary Care Physician
Phone
Format: (000) 000-0000.
Date of last annual exam
/
Month
/
Day
Year
Date
Date of last visit to your PCP
/
Month
/
Day
Year
Date
1
Physician Name
Specialty
2
Physician Name
Specialty
3
Physician Name
Specialty
4
Physician Name
Specialty
SURGICAL HISTORY
List any surgeries, fractures, major illnesses, or hospitalizations that you have had:
1
Surgery Description
Doctor
Location
Year
2
Surgery Description
Doctor
Location
Year
3
Surgery Description
Doctor
Location
Year
4
Surgery Description
Doctor
Location
Year
5
Surgery Description
Doctor
Location
Year
6
Surgery Description
Doctor
Location
Year
7
Surgery Description
Doctor
Location
Year
8
Surgery Description
Doctor
Location
Year
ALLERGIES
List your allergies and describe the reactions to your body:
1
Allergy
Reaction
2
Allergy
Reaction
3
Allergy
Reaction
4
Allergy
Reaction
5
Allergy
Reaction
6
Allergy
Reaction
7
Allergy
Reaction
8
Allergy
Reaction
MEDICATION
List the medications you are currently taking including the dosage:
1
Medication
Dose
Reason
2
Medication
Dose
Reason
3
Medication
Dose
Reason
4
Medication
Dose
Reason
5
Medication
Dose
Reason
6
Medication
Dose
Reason
7
Medication
Dose
Reason
8
Medication
Dose
Reason
List any supplements or compounded medications you are currently taking
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FAMILY HEALTH HISTORY
List any major conditions/illnesses that your immediate family members have had:
1
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
2
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
3
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
4
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
5
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
6
Relative
Condition
Still Living?
Yes
No
If deceased, at what age?
SOCIAL HISTORY
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 do you smoke per day?
Do you currently use any other drugs?
Yes
No
What other drugs do you take?
How often?
Daily
Weekly
Occasionally
Rarely
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?
If you are female, complete the following:
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?
Printed name of Patient or Patient's Legal Representative
*
Signature of Patient or Patient's Legal Representative
Date
/
Month
/
Day
Year
Submit
Should be Empty: