Patient Intake Form

PATIENT INFORMATION

Last Name

First Name

Middle Initial

Date of Birth

Age

Sex

Male Female Other

Social Security Number

Street Address

Apt/Unit

City

State

ZIP Code

Home Phone

Cell Phone

Email Address

Marital Status

Single Married Divorced Widowed

Employer

Occupation

EMERGENCY CONTACT

Name

Relationship

Phone Number

INSURANCE INFORMATION

Primary Insurance Company

Policy Number

Group Number

Policy Holder Name

Relationship to Patient

Policy Holder DOB

MEDICAL HISTORY

Primary Care Physician

Phone

Reason for Today's Visit

Please check any conditions you have or have had:

Diabetes High Blood Pressure Heart Disease Stroke Cancer Asthma Arthritis Thyroid Disease Kidney Disease Liver Disease Depression Anxiety

Current Medications (include dosage)

Allergies (medications, food, environmental)

Previous Surgeries (include dates)

FAMILY HISTORY

Check if any blood relatives have had:

Diabetes Heart Disease High Blood Pressure Stroke Cancer (type: _______) Mental Illness Kidney Disease Other: _______

SOCIAL HISTORY

Do you smoke?

Never Former Current (_____ packs/day)

Alcohol Use

None Social Daily (_____ drinks)

Exercise Frequency

None 1-2x/week 3-4x/week 5+/week

I certify that the above information is correct to the best of my knowledge. I authorize the release of any medical information necessary to process insurance claims. I authorize payment of medical benefits to the physician or supplier for services rendered.

Patient/Guardian Signature

Date