Autoimmune Disease Intake Form
Please complete this form to help us understand your health background and symptoms related to autoimmune conditions.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Non-binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Symptoms (check all that apply)
*
Fatigue
Joint pain or swelling
Muscle weakness
Skin rashes
Digestive issues
Fever
Unexplained weight changes
Hair loss
Numbness or tingling
Other
How long have you been experiencing these symptoms?
*
Current Medications (please list all)
Allergies (medication, food, environmental)
Have you been diagnosed with any autoimmune diseases before?
*
Yes
No
If yes, please specify the autoimmune disease(s) and date of diagnosis.
Family history of autoimmune diseases? (immediate family only)
*
Yes
No
Unknown
If yes, please list the family member(s) and condition(s).
Other significant medical history (chronic illnesses, surgeries, hospitalizations)
Primary Care Physician (name and contact, if applicable)
Submit
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