You may complete online and print out this Standard Intake Form, or you may print out and complete manually. Please bring this form with you to your first office visit. You do not have to fill out this form if you've already submitted an electronic version. All of the information we receive is protected and maintained in accordance with the Health Information Portability and Accountability Act, HIPAA Laws.
Standard Intake Form
for
Checkups and Health Concerns
Demographics:
Patient Name:
Address:
Phone #:
Alternative #:
Date of Birth:
Contact Person:
Phone #:
Relationship:
Medical History:
List all current
medical conditions:
List all previous
medical conditions:
Do you have:
Diabetes?
Heart disease?
Lung disease?
Intestinal disease?
List all surgeries:
Just a few more questions now. You can do it!
Head:
Ears:
Eyes:
Nose:
Throat:
Lungs:
Heart:
Breast:
Gastrointestines:
Sexual Function:
Skin:
Concentration:
Memory:
Finances:
Social Support:
1 = No Concern. 2 = Mild Concern. 3 = Moderately Concerned. 4 = Very Concerned.
You can do it!
Have you had all of the usual childhood vaccinations?
Have you had all of the usual childhood illnesses, including chicken pox?
Social History:
Who do you live with?
Are you being 
abused by anyone?
abused by anyone?Your occupation?
Hobbies?
(optional fields)
Family History:
Does your mother have:
Does your father have:
Do your siblings have:
Other family illnesses:
Are you a smoker?
Do you drink alcohol?
On average, how many drinks do you consume each day?
List other drugs you use:
Have you ever had a problem with drug use?
What's your level of concern with your:
Review of Systems:
Allergies:
Do you have any Allergies to medication?
List all medications you are allergic to:
List all medications and supplements you're taking, need, or have taken in the past: Name, milligrams, and how many times each day you take these.
Chief Concern:
How I can help you, that is, what is your chief concern?
What is the timeframe you'd like to be called in?
Best time of day to call, i.e., M - F, 1 - 4 PM.
What's your level of concern with:
1. Fatigue:
2. Muscleaches:
3. Joint aches:
4. Problems concentrating:
5. Memory problems:
6. Unusal skin sensations:
7. Unusal skin lesions:
Specific Screening:
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