Medical Intake form

Medical Intake form
Name
First NameLast Name
Person Filling Out This Form (if not the Patient)
First NameLast Name
Relationship to the Patient
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
City/State or Town/Country if not in the US
Gender
Marital Status
Did something trigger your change in health?
Blood type
Tuberculosis
When was the last time you had a test for Tuberculosis?
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What was the result?
Have you ever had a positive test for Tuberculosis?
If yes, did you complete ≥6 months of preventative treatment?
Are you experiencing any of the following symptoms?
Have you had known contact with someone known to have TB disease?
Vaccinations
Did you receive your childhood vaccinations?
Rows Yes No Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Allergies
Do you have any allergies?
If yes, please list.
Do you have any drug allergies?
If yes, please list.
Sexual Health
What is your sexuality?
Other
Have you had the tests below?
Rows Yes No Unsure
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test
Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
If yes, please check all that apply
Rows Not Satisfied Somewhat Satisfied Satisfied
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis
Medical History
To your knowledge, have any of your blood relatives had any of the following section?

Surgical History
Rows Yes No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty
Gastroenterology Related Medical History
Rows Past condition Ongoing condition N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease

Cardiology Related Medical History

Rows	Past condition	Ongoing condition	N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other

Endocrine Related Medical History

Rows	Past condition	Ongoing condition	N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other

Nephrology Related Medical History cont.

Rows	Past conditon	Ongoing condition	N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other

Orthopedics Related Medical History cont.
Rows Past condition Ongoing condition N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other

Immune System Related Medical History cont.

Rows	Past condition	Ongoing condition	N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other

Lung Related Medical History
Rows Past condition Ongoing condition N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Cancer History
Rows Past condition Ongoing condition N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Cancer History Cont.
Rows Past condition Ongoing condition N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Medical Health

Mental Health Condition History

Rows	Past condition	Ongoing condition	N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other

Please list any significant physical trauma you've experienced
Please list emotional trauma you've experienced in your life
Gynecological History
Gynecological History

Gynecological History cont.

Rows	Present use	Past use	Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy

Gynecological History cont.
Menopausal patients
Men's history
Other
Dental history

Medication history

Rows	Currently	Past use	Rarely used	Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives

Medications
Supplements
Should be Empty:

Select theme:

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease

Rows	Yes	No	Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis

Rows	Not Satisfied	Somewhat Satisfied	Satisfied
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis

Rows	Yes	No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty

Rows	Past condition	Ongoing condition	N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease

Rows	Past condition	Ongoing condition	N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other

Rows	Past condition	Ongoing condition	N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other

Rows	Yes	No	Unsure
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test

Medical Intake form

Tuberculosis

Vaccinations

Allergies

Sexual Health

Medical History

Medical Health

Gynecological History