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/HeterosexualLesbian/Gay/HomosexualBisexualDon’t KnowChoose not to disclose
Religion:
BuddhistCatholicHinduIslamJehovah’s WitnessJewishMormonProtestantOther:______________________Declined
Spouse’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

Have you ever had a problem with bleeding or clothing?
YesNo
Have 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?
YesNo
Date of last mammogram
List any childhood illnesses you have had:
Children - Are immunizations current?
YesNo
List 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?
YesNo
Number 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

Father:
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):
Cancer