Medical Intake form
Name
First Name
Last Name
Person Filling Out This Form (if not the Patient)
First Name
Last Name
Relationship to the Patient
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
City/State or Town/Country if not in the US
Gender
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Did something trigger your change in health?
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Tuberculosis
When was the last time you had a test for Tuberculosis?
-
Month
-
Day
Year
Date
What was the result?
Have you ever had a positive test for Tuberculosis?
Yes
Unsure
No
If yes, did you complete ≥6 months of preventative treatment?
Yes
No
Unsure
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
Have you had known contact with someone known to have TB disease?
Yes
No
Vaccinations
Did you receive your childhood vaccinations?
Yes
No
Unknown
1
Yes
No
Unknown
HPV (Gardasil)
2
3
4
Tetanus (TdaP)
5
6
7
Hepatitis A
8
9
10
Hepatitis B
11
12
13
Influenza (Flu)
14
15
16
Pneumonia (Pneumovax)
17
18
19
Chicken pox (Varavax)
20
21
22
Shingles (Zostavax)
23
24
25
Meningitis
26
27
28
Allergies
Do you have any allergies?
Yes
No
If yes, please list.
Do you have any drug allergies?
Yes
No
If yes, please list.
Sexual Health
What is your sexuality?
Lesbian
Gay
Bisexual
Queer
Heterosexual
N/A
Other
Have you had the tests below?
Yes
No
Unsure
Cervical Pap Smear
29
30
31
Anal Pap Smear
32
33
34
HIV Test
35
36
37
Hepatitis C Test
38
39
40
Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
Yes
No
If yes, please check all that apply
Not Satisfied
Somewhat Satisfied
Satisfied
HIV/AIDS
41
42
43
Gonorrhea
44
45
46
Chlamydia
47
48
49
Oral Herpes
50
51
52
Yeast Infection
53
54
55
Syphilis
56
57
58
Medical History
To your knowledge, have any of your blood relatives had any of the following section?
None
Unknown
Yes
Family History
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Cancers
59
60
61
62
63
64
Colon
65
66
67
68
69
70
Breast/Ovarian
71
72
73
74
75
76
Heart Disease
77
78
79
80
81
82
Hypertension
83
84
85
86
87
88
Obesity
89
90
91
92
93
94
Diabetes
95
96
97
98
99
100
Stroke
101
102
103
104
105
106
Inflammatory arthritis
107
108
109
110
111
112
Inflammatory Bowel Disease
113
114
115
116
117
118
Multiple Sclerosis
119
120
121
122
123
124
Autoimmune Diseases
125
126
127
128
129
130
Irritable Bowel Syndrome
131
132
133
134
135
136
Celiac Disease
137
138
139
140
141
142
Asthma
143
144
145
146
147
148
Eczema/Psoriasis
149
150
151
152
153
154
Food allergies/sensitivities
155
156
157
158
159
160
Environmental sensitivities
161
162
163
164
165
166
Dementia
167
168
169
170
171
172
Parkinson's
173
174
175
176
177
178
ALS or other motor neuron diseases
179
180
181
182
183
184
Genetic disorders
185
186
187
188
189
190
Substance abuse (alcoholism, etc.)
191
192
193
194
195
196
Psychiatric disorders
197
198
199
200
201
202
Depression
203
204
205
206
207
208
Schizophrenia
209
210
211
212
213
214
ADHD
215
216
217
218
219
220
Austism
221
222
223
224
225
226
Bipolar disease
227
228
229
230
231
232
Surgical History
Yes
No Satisfied
Appendix Removal
233
234
Breast Lumpectomy
235
236
Facial Surgery
237
238
Hysterectomy
239
240
Phalloplasty
241
242
Gastroenterology Related Medical History
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
243
244
245
Crohn's
246
247
248
Ulcerative colitis
249
250
251
Peptic Ulcer disease
252
253
254
GERD (reflux)
255
256
257
Celiac disease
258
259
260
Cardiology Related Medical History
Past condition
Ongoing condition
N/A
Heart Attack
261
262
263
Other Heart disease
264
265
266
Stroke
267
268
269
Elevated cholesterol
270
271
272
Arrhythmia (irregular heart rate)
273
274
275
Hypertension (high blood pressure)
276
277
278
Rheumatic fever
279
280
281
Mitral valve prolapse
282
283
284
Other
285
286
287
Endocrine Related Medical History
Past condition
Ongoing condition
N/A
Type 1 Diabetes
288
289
290
Type 2 Diabetes
291
292
293
Hypoglycemia
294
295
296
Metabolic syndrome (pre-diabetes)
297
298
299
Hypothyroidism (low thyroid)
300
301
302
Hyperthyroidism (overactive thyroid)
303
304
305
Polycystic Ovarian Syndrome
306
307
308
Infertility
309
310
311
Weight gain
312
313
314
Weight loss
315
316
317
Eating disorder
318
319
320
Other
321
322
323
Nephrology Related Medical History cont.
Past conditon
Ongoing condition
N/A
Kidney stones
324
325
326
Gout
327
328
329
Interstitial cystitis
330
331
332
Frequent urinary tract infections
333
334
335
Frequent yeast infections
336
337
338
Erectile dysfunction
339
340
341
Sexual dysfunction
342
343
344
Other
345
346
347
Orthopedics Related Medical History cont.
Past condition
Ongoing condition
N/A
Osteoarthritis
348
349
350
Fibromyalgia
351
352
353
Chronic pain
354
355
356
Other
357
358
359
Immune System Related Medical History cont.
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
360
361
362
Autoimmune disease
363
364
365
Rheumatoid arthritis
366
367
368
Lupus SLE
369
370
371
Immune deficiency disease
372
373
374
Severe infectious disease
375
376
377
Poor Immune function
378
379
380
Other
381
382
383
Lung Related Medical History
Past condition
Ongoing condition
N/A
Asthma
384
385
386
Chronic sinusitis
387
388
389
Bronchitis
390
391
392
Emphysema
393
394
395
Pneumonia
396
397
398
Tuberculosis
399
400
401
Sleep Apnea
402
403
404
Other
405
406
407
Cancer History
Past condition
Ongoing condition
N/A
Eczema
408
409
410
Psoriasis
411
412
413
Acne
414
415
416
Melanoma
417
418
419
Skin Cancer
420
421
422
Other
423
424
425
Cancer History Cont.
Past condition
Ongoing condition
N/A
Lung cancer
426
427
428
Breast cancer
429
430
431
Colon cancer
432
433
434
Ovarian cancer
435
436
437
Prostate cancer
438
439
440
Skin cancer
441
442
443
Other
444
445
446
Medical Health
Mental Health Condition History
Past condition
Ongoing condition
N/A
Depression
447
448
449
Anxiety
450
451
452
Bipolar disorder
453
454
455
Schizophrenia
456
457
458
Headaches
459
460
461
Migraines
462
463
464
ADD/ADHD
465
466
467
Autism
468
469
470
Memory problems
471
472
473
Dementia/Alzheimer's
474
475
476
Parkinson's disease
477
478
479
Multiple Sclerosis
480
481
482
Seizures
483
484
485
Other
486
487
488
Please list any significant physical trauma you've experienced
Please list emotional trauma you've experienced in your life
Gynecological History
Gynecological History
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
Gynecological History cont.
Present use
Past use
Never
Birth control pills
489
490
491
Hormonal patches
492
493
494
Nuva Ring
495
496
497
Condom
498
499
500
Diaphragm
501
502
503
Hormonal IUD
504
505
506
Non-hormonal IUD
507
508
509
Partner Vasectomy
510
511
512
Gynecological History cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Medication history
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
513
514
515
516
Tylenol (Acetaminophen)
517
518
519
520
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
521
522
523
524
Antibiotics
525
526
527
528
Steriods
529
530
531
532
Oral contraceptives
533
534
535
536
Medications
Supplements
Submit
Should be Empty: