Patient Intake Form
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Do you have an idea of what you want to draft, but you cannot find the exact words yet to write it down or lack the inspiration how to make it? If you've been feeling stuck, this Patient Intake Form template can help you find inspiration and motivation. This Patient Intake Form covers the most important topics that you are looking for and will help you to structure and communicate in a professional manner with those involved.
Date: Insurance: (dd/mm/yr) Date of Birth: □ male □ female Address: Marital status S M W D SEP Phone : home: work: E-mail address: Occupation: Employer: Check and indicate the age when you had any of the following: General □ Allergies □ Depression □ Dizziness □ Fainting □ Fatigue □ Fever □ Headaches □ Loss of sleep □ Mental illness □ Nervousness □ Tremors □ Weight loss / gain Muscle / Joint □ Arthritis / rheumatism □ Bursitis □ Foot trouble □ Muscle weakness □ Low back pain □ Neck pain □ Mid back pain □ Joint pain Skin □ Boils □ Bruise easily □ Dryness □ Hives or allergies □ Itching □ Rash □ Varicose veins Eye, Ear, Nose Throat □ Colds □ Deafness □ Ear ache □ Eye pain □ Gum trouble □ Hoarseness □ Nasal obstruction □ Nose bleeds □ Ringing of the ears □ Sinus infection □ Sore throat □ Tonsillitis □ Vision problems Gastrointestinal □ Abdominal pain □ Bloody or tarry stool □ Colitis / Crohn’s □ Colon trouble □ Constipation □ Diarrhea □ Difficult digestion □ Diverticulosis □ Bloated abdomen □ Excessive hunger □ Gallbladder trouble □ Hernia □ Hemorrhoids □ Intestinal worms □ Jaundice □ Liver trouble □ Nausea □ Painful deification □ Pain over stomach □ Poor appetite □ Vomiting □ Vomiting of blood Genitourinary □ Bed-wetting □ Bladder infection □ Blood in urine □ Kidney infection □ Kidney stones □ Prostate trouble □ Pus in urine □ Stress incontinence Urination □ Overnight more than twice □ More than 8x in 24hrs □ Decreased flow/force □ Painful urination □ Urgency to urinate Cardiovascular □ High blood pressure □ Low blood pressure □ Hardening of the arteries □ Irregular pulse □ Pain over heart □ Palpitation □ Poor circulation □ Rapid heart beat □ Slow heart beat □ Swelling of ank
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