Veteran Health Exam Intake

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact (Name and Phone)

Do you have health insurance?

Please list any current medications you are taking.

Do you have any allergies?

If yes, please list your allergies.

Have you ever been diagnosed with any of the following conditions?

Please indicate any current symptoms or concerns.

Do you currently smoke or use tobacco products?

How often do you consume alcohol?

In the past month, how often have you felt down, depressed, or hopeless?