Patient Intake Form Patient InformationPatient's Name *Date of Birth Age Sex MaleFemaleStreet Address PermanentTemporaryCity and State Zip Code - Business Phone No. Patient’s Employer Occupation How Long Emp.? - Cell Phone No. Employer’s Street Address City and State Zip Code Primary Care Physician PCP Phone # How did you hear about us? Please check all that apply: (These questions are required by the Federal Government to meet Meaningful Use Guidelines - you may decline to answer by checking DECLINED in each column.)Marital Status: MarriedSingleDivorcedSeparatedWidowedDeclinedRace: American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteOther:____________________________DeclinedEthnicity: Hispanic/LatinoNot Hispanic/LatinoDeclined*Sexual Orientation *State Regulations Require us to include these questions, you do not have to answer.*Straight/HeterosexualLesbian/Gay/HomosexualBisexualDon’t KnowChoose not to discloseReligion: BuddhistCatholicHinduIslamJehovah’s WitnessJewishMormonProtestantOther:______________________DeclinedSpouse’s Name Spouse’s Date of Birth Spouse’s Social Security No. Spouse’s Employer Employer’s Street Address City and State - Zip Code Spouse’s Occupation How Long Emp.? Spouse’s Business Phone No. In Case of Emergency Contact (Not living with you) Relationship Home Phone - Business Phone Contact’s Street Address City and State Zip Code IF THE PATIENT IS A MINOR OR STUDENTMother’s Name Date of Birth Social Security No. - Home Phone No. Street Address, City, Sate and Zip Code Mother’s Employer Occupation Employer’s Street Address, City, State and Zip Code Business Phone Father’s Name Date of Birth Social Security No. - Home Phone No. Street Address, City, Sate and Zip Code Father’s Employer Occupation Employer’s Street Address, City, State and Zip Code Business Phone Past Medical HistoryHave you ever had a problem with bleeding or clothing? YesNoHave you had or presently have any of the following? (check) Aids or tested HIV positiveDiabetesCancerTuberculosisPneumoniaEpilepsyHepatitis (Type: o A o B o C)AnemiaHeart DiseaseLung DiseaseMuscle DiseaseNervous ConditionsKidney DiseaseLiver DiseaseSkin CancerMental IllnessHeart MurmurIrregular Heart BeatsHigh Blood PressureBleeding TendenciesStomach/Intestinal DiseaseRheumatic FeverCancer of BreastHeart AttackStrokeThyroid DiseaseLast tetanus_______________Are you pregnant? YesNoDate of last mammogram List any childhood illnesses you have had: Children - Are immunizations current? YesNoList any serious injuries you have received and when they occured: Previous hospitalizations/surgeries: Reason1: Date1: Location1: Reason2: Date2: Location2: Reason3: Date3: Location3: Reason4: Date4: Location4: Reason5: Date5: Location5: GYN: Date of last menstrual period: Are your periods regular? YesNoNumber of births: Number of pregnancies: Number of miscarriages: Medications: please list all prescriptions/vitamins/birth control/over the counter/herbal supplements, their dosage and how many times you take per day. Drug Allergies: please include the name of the medication and reaction. Food Allergies: please list any food allergies Family HistoryFather: Age: Living: Dead: Cause of Death: Major Diseases: Mother Age: Living: Dead: Cause of Death: Major Diseases: Sisters Age: Living: Dead: Cause of Death: Major Diseases: Brothers Age: Living: Dead: Cause of Death: Major Diseases: Check any illnesses that have affected any close relatives (parents, siblings): CancerHeart AttacksStrokesDiabetesHemophiliaHeart DiseaseRheumatic FeverSickle Cell AnemiaBleeding TendenciesHigh Blood PressureBrain HemorrhageBreast CancerOthers Social HistoryDo your live alone? YesNoOccupation: Habits Smoking: YesNo CigarettesPipeCigarsOtherHow Much? Former Smoker? YesNoWhen dis you stop? How long? Alcohol: NoneOccasionallyFrequentlyHow Much? Please answer the following regarding your health: Have you had recent fevers or chills? YesNoHave you had a significant change in weight? YesNoIncrease or Decrease? IncreaseDecrease?How Much? Do you have tearing, dry eyes, wear contacts or glasses? YesNoDo you have a problems with your hearing, sore throats, congested sinus or snoring? YesNoDo you get tightness, pressure, or squeezing in your chest? YesNoAre you under treatment for high blood pressure? YesNoDo you frequently suffer from chest colds, chronic coughing, bronchitis, asthma or difficulty breathing? YesNoHave you had diarrhea, nausea or vomiting? YesNoHave you had a recent change in bowel habits? YesNoDo you have burning with urination? YesNoDo you have pain in the joints, muscle aches or spasms? YesNoWhere? Have you noticed a change in a mole or skin lesion? YesNoDescribe(Size,color, shape, itching or bleeding): Have you had excessive exposure to the sun or a tanning bed? YesNoHave you had or do you have a breast lump? YesNoDo you perform a regular breast self-examination? YesNoAre you under treatment for depression? YesNoHave you ever had a blood transfusion before? YesNowhen? Have you ever had a blood transfusion reaction? YesNoWhen: Has anyone in you family had bleeding tendencies or hemophilia? YesNoPlease list any additional information you feel in pertinent to you care: Signature: *Date: VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
