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/Heterosexual