Telemedicine Patient Intake Form

Name

First NameLast Name

Birth Date

Date

Gender

FemaleMale

Email

example@example.com

Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Insurance Provider

Insurance Card (Front)

Insurance Card (End)

Check all symptoms that apply

List out your family members that have the symptoms mentioned above

Please select the option that applies regarding your smoking habits

None0 -1 package a day1 - 2 packages a day2+ packages a day

Average # alcoholic drinks per week?

Average hour of sleep per week?

Average # of workouts per week?

List any chronic health problems you may have

List out all current medication

List out allergies

Have you received any outpatient treatment for a psychiatric condition ?

Have you been hospitalized? If so, please elaborate.

Is there anything else that you would like us to know?

What problems are you seeking help for?

What days work best for you?

What time works best for you?

MorningAfternoonEvening

Date

Signature