Eidon Tech - Patient Intake Demo

Patient Intake - Demo Form
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Email Address
example@example.com
Date of Last Office Visit

MonthDayYear
Date
Are you currently under a physician's care?

YesNo
Physician's Name:

First NameLast Name
Physician's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone:

Area CodePhone Number
Please explain:
This is a test. Can you see me?
Have you ever been hospitalized or had a major surgery?

YesNo
If yes, please explain:
Have you ever had a serious head or neck injury?

YesNo
If yes, please explain:
Do you have, or have you had, any of the following? Please check all that apply:

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatism
Do you have any drug allergies?

YesNoNot Sure
Please list all drug allergies:
Do you use or do you have history of using tobacco?
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Please upload any notes or documents necessary for your upcoming visit:

Browse Files
ex. referrals, immunization records, etc. Cancelof
Patient Signature

Clear
________________________________

Reviewed By (Doctor's Signature)

____________________

Date

Additional Notes:
Should be Empty:

Patient Intake - Demo Form