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Patient Intake Form

Patient Information

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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
Race
Ethnicity
*Sexual Orientation
*State Regulations Require us to include these questions, you do not have to answer
Religion

IF THE PATIENT IS A MINOR OR STUDENT

Past Medical History

Have you ever had a problem with bleeding or clothing?
Have you had or presently have any of the following? (check)
Are you pregnant?
Children - Are immunizations current?

Previous hospitalizations/surgeries

GYN

Are your periods regular?

Family History

Father

Mother

Sisters

Brothers

Check any illnesses that have affected any close relatives (parents, siblings)

Social History

Do your live alone?
Smoking
Untitled
Former Smoker
Alcohol

Please answer the following regarding your health

Have you had a significant change in weight?
Have you had recent fevers or chills?
Do you have tearing, dry eyes, wear contacts or glasses?
Do you have a problems with your hearing, sore throats, congested sinus or snoring?
Do you get tightness, pressure, or squeezing in your chest
Are you under treatment for high blood pressure?
Do you frequently suffer from chest colds, chronic coughing, bronchitis, asthma or difficulty breathing?
Have you had diarrhea, nausea or vomiting?
Have you had a recent change in bowel habits?
Do you have burning with urination?
Do you have pain in the joints, muscle aches or spasms?
Have you noticed a change in a mole or skin lesion?
Have you had excessive exposure to the sun or a tanning bed?
Have you had or do you have a breast lump?
Do you perform a regular breast self-examination?
Are you under treatment for depression?
Have you ever had a blood transfusion before?
Have you ever had a blood transfusion reaction?
Has anyone in you family had bleeding tendencies or hemophilia?
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This field is for validation purposes and should be left unchanged.