New Patient Intake Form (Adult)
Demographic Information
Pronouns:
Please Select
She/Her
He/Him
They/Them
Name
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number:
Please enter a valid phone number.
Emergency Contact
First Name
Last Name
Emergency Contact Cell Phone Number
Please enter a valid phone number.
Relationship to Patient:
Are we your Primary Care Provider (PCP)?
Yes
No
If no, Primary Care Physician’s Name:
First Name
Last Name
Primary Care Provider’s Location:
Front of Insurance Card:
Back of Insurance Card:
Medical History
Allergies
Please enter in your allergies, what kind of reaction you experience, and the severity of the reaction (mild, moderate, or severe).
Medications
Please enter in all your medications, as well as dosage, and how often you take it?
Supplements
Please enter in all your supplements, as well as dosage, and how often you take it?
Surgeries
Please enter in all surgeries you have had and the year they were preformed.
Family Health History
Mother
Maternal Grandfather
Maternal Grandmother
Maternal Uncle
Maternal Aunt
Father
Paternal Grandfather
Paternal Grandmother
Paternal Uncle
Paternal Aunt
Sister
Brother
Stroke
Heart Attack
High Blood Pressure
High Cholesterol
Diabetes
Aneurism
Cancer
Rheumatoid Arthritis
Thyroid Disorder
Multiple Sclerosis
Lupus
Other Autoimmune Disease
Anxiety
Depression
Bipolar Disorder
Schizophrenia
Social History
None
Daily Use
Weekly Use
Monthly Use
Rare Use
Alcohol Intake
Marijuana
Cigarette Smoker
Other Drug Use
Submit
Should be Empty: