Patient Intake FormPatient InformationPatient's Name(Required)Date of Birth MM slash DD slash YYYY AgeSexStreet AddressCity and StateZip Code - Business Phone No.Patient’s EmployerOccupationHow Long Emp.? - Cell Phone No.Employer’s Street AddressCity and StateZip CodePrimary Care PhysicianPCP Phone #How did you hear about us?Note: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 Married Single Divorced Separated Widowed DeclinedRace American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White DeclinedEthnicity Hispanic/Latino Not Hispanic/Latino Declined*Sexual Orientation Straight/Heterosexual Lesbian/Gay/Homosexual Bisexual Don’t Know Choose not to disclose*State Regulations Require us to include these questions, you do not have to answerReligion Buddhist Catholic Hindu Islam Jehovah’s Witness Jewish Mormon Protestant Other DeclinedSpouse’s NameSpouse’s Date of BirthSpouse’s Social Security No.Spouse’s EmployerEmployer’s Street AddressCity and State - Zip CodeSpouse’s OccupationHow Long Emp.?Spouse’s Business Phone No.In Case of Emergency Contact (Not living with you)RelationshipHome Phone - Business PhoneContact’s Street AddressCity and StateZip CodeIF THE PATIENT IS A MINOR OR STUDENTMother’s NameDate of BirthSocial Security No. - Home Phone No.Street Address, City, Sate and Zip CodeMother’s EmployerOccupationEmployer’s Street Address, City, State and Zip CodeBusiness PhoneFather’s NameDate of BirthSocial Security No. - Home Phone NoStreet Address, City, Sate and Zip CodeFather’s EmployerOccupationEmployer’s Street Address, City, State and Zip CodeBusiness PhonePast Medical HistoryHave you ever had a problem with bleeding or clothing? Yes NoHave you had or presently have any of the following? (check) Aids or tested HIV positive Diabetes Cancer Tuberculosis Pneumonia Epilepsy Hepatitis (Type: o A o B o C) Anemia Heart Disease Lung Disease Muscle Disease Nervous Conditions Kidney Disease Liver Disease Skin Cancer Mental Illness Heart Murmur Irregular Heart Beats High Blood Pressure Bleeding Tendencies Stomach/Intestinal Disease Rheumatic Fever Cancer of Breast Heart Attack Stroke Thyroid Disease Last tetanusAre you pregnant? Yes NoDate of last mammogramList any childhood illnesses you have hadChildren - Are immunizations current? Yes NoList any serious injuries you have received and when they occurred:Previous hospitalizations/surgeriesReason 1Date 1Location 1Reason 2Date 2Location 2Reason 3Date 3Location 3Reason 4Date 4Location 4Reason 5Date 5Location 5GYNDate of last menstrual periodAre your periods regular? Yes NoNumber of birthsNumber of pregnanciesNumber of miscarriagesMedications: please list all prescriptions/vitamins/birth control/over the counter/herbal supplements, their dosage and how many times you take per dayDrug Allergies: please include the name of the medication and reactionFood Allergies: please list any food allergiesFamily HistoryFatherAgeLivingDeadCause of DeathMajor DiseasesMotherAgeLivingDeadCause of DeathMajor DiseasesSistersAgeLivingDeadCause of DeathMajor DiseasesBrothersAgeLivingDeadCause of DeathMajor DiseasesCheck any illnesses that have affected any close relatives (parents, siblings) Cancer Heart Attacks Strokes Diabetes Hemophilia Heart Disease Rheumatic Fever Sickle Cell Anemia Bleeding Tendencies High Blood Pressure Brain Hemorrhage Breast CancerOthersSocial HistoryDo your live alone? Yes NoOccupationSmoking Yes NoUntitled Cigarettes Pipe Cigars OtherHow MuchFormer Smoker Yes NoWhen dis you stop?How long?Alcohol None Occasionally FrequentlyHow Much?Please answer the following regarding your healthHave you had a significant change in weight? Yes NoIncrease or Decrease?Have you had recent fevers or chills? Yes NoHow Much?Do you have tearing, dry eyes, wear contacts or glasses? Yes NoDo you have a problems with your hearing, sore throats, congested sinus or snoring? Yes NoDo you get tightness, pressure, or squeezing in your chest Yes NoAre you under treatment for high blood pressure? Yes NoDo you frequently suffer from chest colds, chronic coughing, bronchitis, asthma or difficulty breathing? Yes NoHave you had diarrhea, nausea or vomiting? Yes NoHave you had a recent change in bowel habits? Yes NoDo you have burning with urination? Yes NoDo you have pain in the joints, muscle aches or spasms? Yes NoWhereHave you noticed a change in a mole or skin lesion? Yes NoDescribe(Size,color, shape, itching or bleeding)Have you had excessive exposure to the sun or a tanning bed? Yes NoHave you had or do you have a breast lump? Yes NoDo you perform a regular breast self-examination? Yes NoAre you under treatment for depression? Yes NoHave you ever had a blood transfusion before? Yes NoWhen?Have you ever had a blood transfusion reaction? Yes NoWhen?Has anyone in you family had bleeding tendencies or hemophilia? Yes NoPlease list any additional information you feel in pertinent to you careSignature(Required)Date(Required) MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
