History of Present Illness Intake Form
Please complete the History of Present Illness Intake Form to help us understand your current health concerns.
Full Name
*
First Name
Last Name
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the main reason for your visit today?
*
When did your symptoms begin?
*
Describe the location of your symptoms.
How would you describe the quality of your symptoms?
Please Select
Sharp
Dull
Aching
Burning
Other
Rate the severity of your symptoms
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
What makes your symptoms better or worse?
Are there any other symptoms you are experiencing?
Have you tried any treatments or interventions for these symptoms?
Submit
Should be Empty: