This form is designed to gather essential information needed to provide comprehensive and safe care during your appointment. Please complete all sections to the best of your ability.
First Name
Middle Name
Last Name
Date of Birth
Sex Assigned at Birth
Gender Identity
Preferred Pronouns
Primary Language
Marital Status
Primary Phone Number
Secondary Phone Number
Email Address
Street Address Line 1
Street Address Line 2
City/Town
State/Province/Region
Postal/Zip Code
Date of Appointment
Time of Appointment
Reason for Visit
New Symptoms/Concern
Follow-up
Annual Physical/Check-up
Prescription Refill
Other:
Brief Description of Current Symptoms/Concerns
How long have you had these symptoms?
First Name
Middle Name
Last Name
Relationship to Patient
Phone Number
Please list all prescription medications, over-the-counter medications, vitamins, and herbal supplements you are currently taking.
Medication/Supplement Name | Dosage (e.g., 10mg) | Frequency (e.g., Once Daily) | ||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Allergy Type | Select | Substance (e.g., Penicillin, Peanuts, Latex) | Reaction (e.g., Rash, Anaphylaxis) | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Medication | ||||
2 | Food | ||||
3 | Environmental | ||||
4 | None known |
Please check all that apply and provide the approximate year of diagnosis if possible.
Medical Condition | Select | Approximate Year of Diagnosis | ||
|---|---|---|---|---|
A | B | C | ||
1 | High Blood Pressure (Hypertension) | |||
2 | High Cholesterol | |||
3 | Diabetes (Type 1 or 2) | |||
4 | Asthma / COPD | |||
5 | Heart Disease / Stroke | |||
6 | Cancer | |||
7 | Depression / Anxiety | |||
8 | Thyroid Disorder | |||
9 | Kidney Disease |
Procedure | Reason | Approximate Year | ||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Do you currently use tobacco products (cigarettes, vape, chew)?
If Yes, specify amount/frequency:
Do you consume alcohol?
If Yes, specify frequency and amount:
Do you use recreational substances?
If Yes, specify substance and frequency:
Level of Physical Activity
Choice A
Choice B
Sedentary
Moderately Active
Very Active
Occupation
I verify that the information provided on this form is accurate to the best of my knowledge.
Patient/Guardian Signature:
To configure an element, select it on the form.