Patient Intake Form

Patient's Name *
Date of Birth
Age
Sex
Street Address
PermanentTemporary
City 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:
MarriedSingleDivorcedSeparatedWidowedDeclined
Race:
American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteOther:____________________________Declined
Ethnicity:
Hispanic/LatinoNot Hispanic/LatinoDeclined
*Sexual Orientation
*State Regulations Require us to include these questions, you do not have to answer.*Straight/Heterosexual