Patient Intake Form
Please fill in all the fields to the best of your knowledge so we can create an accurate health profile for you. This helps us to serve you better.

PATIENT INFORMATION			
FIRST NAME	MIDDLE NAME	LAST NAME	
			
DATE OF BIRTH	GENDER	EMAIL	
			
CONTACT INFORMATION			
PHONE (HOME)	PHONE (CELL)	PHONE (WORK)	
			
ADDRESS  (STREET, APARTMENT, CITY, STATE, ZIP CODE)			
			
EMERGENCY CONTACT INFORMATION			
NAME	RELATIONSHIP		
			
PHONE (HOME)	PHONE (CELL)	PHONE (WORK)	
			
INSURANCE INFORMATION			
PAYER NAME	PLAN NAME	MEMBER ID	
			
GROUP NUMBER	RELATIONSHIP TO INSURED	SSN	
OTHER PROVIDERS			
PRIMARY CARE PHYSICIAN NAME	PHONE	PRACTICE NAME	
			
REFERRING PHYSICIAN NAME	PHONE	PRACTICE NAME	
			
REASON FOR VISIT			
CHIEF COMPLAINT (HISTORY OF COMPLAINT, SYMPTOMS, ETC)			

			
			
ALLERGIES			

MEDICATIONS (CURRENTLY TAKING, FREQUENCY, DOSAGE)			

			
PAST MEDICAL CONDITIONS			

PAST SURGERIES			

SOCIAL HISTORY			
SMOKING START DATE	SMOKING END DATE	PACKS / DAY	
			
ALCOHOL USE	FREQUENCY	GLASSES / DAY	
			
DRUG USE	ILLICIT DRUGS	IV DRUGS	
			
DRIVING			
			
CAFFEINE USE	FREQUENCY	CUPS / DAY	
			
EXERCISE 			
OCCUPATION			
			
FAMILY HISTORY			
MOTHER	FATHER	SISTER	
			
BROTHER	DAUGHTER	SON