Partners in Care: Your Patient Intake & History Verification

Patient Information

Full Name

First Name

Middle Name

Last Name

Date of Birth

Gender

Occupation

Phone Number

Email Address

Residential Address

Street Address

City

State/Province

Postal/Zip Code

Emergency Contact Name

First Name

Middle Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone Number

Primary Concern & Current Health Status

Reason for Visit: What is the main concern you would like to address today?

Symptom Timeline: When did this concern begin? Was it a sudden or gradual onset?

Symptom Severity: On a scale of 1–10 (1 being minimal, 10 being extreme), how would you rate your discomfort?

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Aggravating/Relieving Factors: What makes the symptoms better or worse?

Prior Treatments: Have you sought treatment for this specific issue elsewhere? (e.g., physical therapy, specialist, alternative medicine).

Medical & Surgical History

Cancer Type

Year of Diagnosis

Surgical History: Please list any major surgeries and the approximate dates.

	Type of Surgery	Approximate Date
	A	B
1
2
3
4
5

Hospitalizations: Have you been hospitalized for any non-surgical reasons in the last 5 years?

Medications & Allergies

Current Medications: Please list all prescription drugs, dosages, and frequency.

	Medicine Name	Dosage	Frequency
	A	B	C
1
2
3
4
5

Supplements: List any vitamins, minerals, herbal remedies, or over-the-counter medications.

Allergies (Drug): List any adverse reactions to medications (e.g., Penicillin, Latex, Sulfa).

	Allergen	Allergic Reaction
	A	B
1
2
3
4
5

Allergies (Environmental/Food): List any known allergies to foods or environmental factors.

	Allergen	Allergic Reaction
	A	B
1
2
3
4
5

Family Health History

Cancer Type

Lifestyle & Wellness Assessment

Sleep: How many hours do you sleep on average? Do you wake up feeling rested?

Nutrition: How would you describe your typical diet? (e.g., Balanced, High-protein, Vegetarian, Processed-heavy).

Physical Activity: Type and frequency of exercise per week.

Substance Use

Tobacco/Nicotine

Current

Former

Never

Alcohol: (Frequency and quantity)

Recreational Drugs: (Frequency and type)

Stress Levels: On a scale of 1–10, how would you rate your daily stress?

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System Review (Functional Health)

Administrative & Compliance

Preferred Pharmacy: (Name and Location)

Primary Care Provider: (Name and Clinic)

Communication Preference: How do you prefer to receive appointment reminders?

Verification Statement

I certify that the above information is correct to the best of my knowledge.

I understand that providing incomplete or inaccurate information may affect the safety and efficacy of my care.

Signature

Form Template Insights

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Detailed Insights on the Patient Intake & History Verification Form Template

1. The Logical Progression (The "Narrative")

A well-designed form follows the natural flow of a conversation. It begins with Identity (who you are), moves to Urgency (why you are here), explores History (how you got here), and finishes with Lifestyle (how you live). This sequence helps the patient feel that the provider is building a complete picture of their life, rather than just checking boxes.

2. Identification as a Safety Anchor

The first section serves as the "anchor." Beyond simple filing, asking for a Preferred Name and Pronouns builds immediate rapport and trust. In a wellness context, feeling seen and respected is the first step toward a positive health outcome.

3. The Subjective vs. Objective Balance

The Subjective: Questions about "Reason for Visit" and "Symptom Severity" capture the patient’s personal experience. This is vital because two people with the same clinical condition may experience vastly different levels of distress.
The Objective: Questions about "Medications" and "Surgical History" provide the hard facts. The "Verification" aspect of the form ensures that the subjective goals are grounded in these objective realities.

4. Uncovering "Hidden" Risks

The Supplements and Over-the-Counter section is often the most revealing. Many patients do not consider herbal teas, vitamins, or daily aspirin as "medicine." However, these can significantly impact blood pressure, heart rate, or skin sensitivity. Forcing a distinction between "Prescriptions" and "Supplements" ensures these details aren't missed.

5. Lifestyle as a Preventative Tool

The Lifestyle & Wellness section shifts the form from "reactive" (fixing a problem) to "proactive" (maintaining health).

Sleep and Stress: These are often the root causes of physical symptoms.
Substance Use: This isn't about judgment; it’s about understanding how the body processes nutrients and recovers from treatment.

6. The System Review (The "Safety Net")

The System Review acts as a safety net for things the patient might have forgotten. A patient visiting for back pain might not think to mention "digestive issues" or "numbness," but to a practitioner, these symptoms together might point to a specific nerve issue that changes the entire approach to care.

7. The Psychology of the Verification Statement

Ending with a Verification Statement serves a "common sense" purpose: it encourages the patient to pause and review their answers. It shifts the responsibility of accuracy to the patient, ensuring they understand that the quality of the advice or treatment they receive is directly linked to the honesty of the data they provide.

8. Accessibility and Clarity

A template should avoid overly dense clinical jargon. Using terms like "Aggravating Factors" is fine, but adding a parenthetical like "(What makes it worse?)" makes the form accessible to people of all literacy levels, reducing the "form fatigue" that leads to skipped questions.

Mandatory Questions Recommendation

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Mandatory Questions & Core Rationale:

1. Full Legal Name and Date of Birth

Why: These are the primary identifiers used to distinguish one person from another. In a healthcare environment, misidentification can lead to the wrong treatment being applied to the wrong person. The date of birth also allows the practitioner to evaluate health risks associated with specific life stages or ages.

2. Allergies (Specifically Drug and Environmental)

Why: This is the most critical safety question. Knowing if a person has a severe reaction to substances like latex, specific medications, or topical oils is essential to prevent immediate physical harm. Without this information, any intervention carries an unnecessary risk of a systemic reaction.

3. Current Medications and Supplements

Why: Many natural supplements and prescription drugs interact poorly with one another or with specific manual therapies. To provide a helpful service, the practitioner must know what chemistry is already active in the person's body to avoid contraindications or reduced efficacy of the treatment.

4. Chronic Conditions (Heart Disease, Diabetes, etc.)

Why: Certain health conditions change how the body responds to stress, temperature, or physical pressure. For example, knowing if a person has a heart condition or high blood pressure is vital before recommending vigorous activity or treatments that affect circulation.

5. Primary Concern or Reason for Visit

Why: This defines the scope of the interaction. It ensures the practitioner stays focused on the person’s actual goals and helps determine if the provider’s expertise is the right match for the specific issue at hand.

6. Emergency Contact Information

Why: If a person experiences a sudden health event—such as a fainting spell or a blood sugar drop—while in the care of a wellness professional, having a direct line to a designated contact is a basic safety requirement to ensure the person is cared for beyond the office doors.

7. Recent Surgeries or Hospitalizations

Why: The body requires time to heal after major physical events. Knowing about recent surgeries helps the practitioner avoid areas of the body that are still recovering or fragile, ensuring the session supports healing rather than disrupting it.

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