New Patient Intake Form

I. Demographics and Contact Information

First Name:

Last Name:

Preferred Name (if different):

Date of Birth:

Gender:

Street Address:

City/Suburb:

State/Province:

Postal/Zip Code:

Phone Number:

Email:

Preferred Method of Contact:

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship:

Marital Status:

Preferred Language:

Occupation:

Employer:

II. Insurance Information

Primary Insurance (if applicable)

Company Name:

Policy Number:

Group Number:

Name of Insured (if different from patient):

Date of Birth of Insured (if different from patient):

Secondary Insurance (if applicable)

Company Name:

Policy Number:

Group Number:

Name of Insured (if different from patient):

Date of Birth of Insured (if different from patient):

III. Medical History

What brings you in today?

When did your symptoms begin?

How long have you had these symptoms?

How often do you experience these symptoms?

What makes your symptoms better?

What makes your symptoms worse?

Past Medical History:

Please list any significant illnesses, injuries, surgeries, or hospitalizations you have had in the past. For each condition, please include the approximate date of diagnosis or occurrence, any treatments you received, and any lasting effects.

	Condition/Procedure	Approximate Date	Treatment	Outcome (Lasting Effects)
	A	B	C	D
1
2
3
4
5
6
7
8
9
10

Current Medications:

	Medication Name	Dosage	Frequency	Route (e.g., oral, topical, injection)	Prescribing Doctor	Reason for Taking
	A	B	C	D	E	F
1
2
3
4
5
6
7
8
9
10

Allergies:

	Allergen (e.g., Medication, Food, Other)	Reaction (e.g., Rash, Hives, Swelling, Anaphylaxis)
	A	B
1
2
3
4
5
6
7
8
9
10

Immuization History:

	Name of Vaccine	Date Received	Booster (if applicable)
	A	B	C
1
2
3
4
5
6
7
8
9
10

Family Medical History:

	Condition	Relative	Age at Diagnosis (if known)
	A	B	C
1
2
3
4
5
6
7
8
9
10

Social History:

Smoking Status:

Current Smoker

Former Smoker

Never Smoke

On days that you drink, how many alcoholic beverages do you typically consume?

Drug Use (excluding prescribed medications):

Never Used

Used in the Past

Currently Using (If currently using, please specify):

What type of exercise do you typically do?

Dietary Habits (e.g., Balanced diet, Mostly vegetarian, High in processed foods, Low carb, etc.):

IV. Review of Systems

Have you noticed any of the following recently? Please check all that apply.

Skin:

Rashes

Itching

Dryness

Changes in moles

Cardiovascular:

Chest pain

Palpitations

Shortness of breath

Swelling in legs

Respiratory:

Cough

Wheezing

Sputum production

Genitourinary:

Changes in urination

Pain

Discharge

Musculoskeletal:

Joint pain

Stiffness

Swelling

Muscle weakness

Psychiatric:

Depression

Anxiety

Mood changes

Sleep disturbances

Endocrine:

Changes in appetite

Thirst

Weight

Energy levels

V. Patient Authorization and Consent

I consent to receive medical treatment from [Practice Name] and its healthcare providers. I understand that this may include examinations, tests, procedures, and other forms of care as deemed necessary by my healthcare provider. I authorize [Practice Name] to bill my insurance company for services rendered and to release necessary information to process insurance claims. I also authorize [Practice Name] to release information about my health to other healthcare providers involved in my care, as needed. I understand that I have the right to ask questions about my treatment and to refuse any treatment I do not want. I also understand that I am responsible for informing the practice of any changes to my insurance or contact information.

I understand that I am financially responsible for all services rendered by [Practice Name]. I am responsible for paying any co-pays, deductibles, co-insurance, and other fees not covered by my insurance. I understand that my insurance company may not cover all services, and I am responsible for paying for any non-covered services. I agree to pay all charges within [Number] days of billing. I understand that I may be subject to collections if my account becomes delinquent. I have received a copy of [Practice Name]'s financial policies.

Please sign here:

Form Template Instructions

Please remove Form Template Instructions before publishing the form.

Important Considerations

Keep it concise: Patients are more likely to complete shorter forms.
Use clear and simple language: Avoid medical jargon.
Provide space for detailed answers: Especially for chief complaint and current symptoms.
Consider using a digital format: This can streamline the process and improve data accuracy.
Review and update the form regularly: Ensure it meets your practice's needs and complies with current regulations.
Consult with legal counsel: To ensure your forms are legally compliant.
Legal Requirements: Consult with legal counsel to ensure you are meeting all legal requirements for mandatory information in your jurisdiction.
Purpose of the Form: Consider the specific goals of your intake form. If you are focusing on a particular specialty, some questions may be more relevant than others.
Patient Comfort: Be mindful of patient privacy and avoid asking for information that is not truly necessary.
"Prefer not to say" Option: For sensitive questions that are not absolutely mandatory, consider offering a "Prefer not to say" option.

Instructions for I. Demographics and Contact Information

If your practice specializes in a particular area (e.g., occupational health), you might need more specific categories related to that field.
You could also ask about industry rather than specific job title, as this might be more relevant in some cases.
Relevance to your practice: How will you use this information? If it's not critical, a free-text field might be sufficient. If it's important for understanding potential exposures or risks, you might need more detail.
Sensitivity: Some people may be hesitant to share their occupation. A free-text field allows them to be as specific or general as they feel comfortable with.
Data Entry: Dropdown menus are easier for data entry but can be cumbersome if the list is too long.
Privacy: Be mindful of patient privacy. Only collect information that is truly necessary.
If you run specific campaigns, list those. For example, if you advertise on a particular radio station, include that.
If you have partnerships with specific organizations, include them.
Data Analysis: How will you use this data? More detailed options allow for better tracking of marketing effectiveness.
Ease of Use: A long list can be overwhelming. Balance detail with simplicity.
Open-ended vs. Closed-ended: Closed-ended questions (multiple choice) are easier to analyze, but open-ended questions (free text) can provide valuable insights.
Digital Forms: Dropdown menus are ideal for digital forms, but be mindful of length.

Instructions for III. Medical History

Ample Space: Provide enough space for patients to write detailed descriptions.
Clarity: Use clear and simple language, avoiding medical jargon.
Open-ended Questions: Encourage patients to provide as much information as possible.
Relevance: Tailor any checklists or diagrams to your specific practice.
Over-the-counter medications and supplements: Encourage patients to include all medications, including over-the-counter drugs, vitamins, herbal supplements, and homeopathic remedies. These can interact with prescription medications.
"As needed" medications: For medications taken "as needed" (prn), ask patients to describe the conditions under which they take the medication and how often they typically take it.
Allergies: This is not the place for allergies. Allergies should be listed in a separate, clearly marked section of the intake form. Mixing allergies with medications can be dangerous.
"None" Option: Make it very clear that patients should write "None" if they have no allergies. This prevents accidental omissions.
Emphasis: Make the "Allergies" section prominent on the form. Use bolding, a different font, or a highlighted box to draw attention to it.
Follow-up: Always verbally confirm allergies with the patient during the intake process, even if they have written "None" on the form.
Childhood Vaccines: Many adults won't remember the exact dates of their childhood immunizations. Encourage them to provide as much information as they can recall.
Travel Vaccines: If travel history is relevant to your practice, specifically ask about travel vaccinations.
Reactions: It's important to know if a patient has had any adverse reactions to vaccines in the past.
Documentation: Emphasize the importance of bringing immunization records to appointments if available.
Electronic Health Records (EHRs): If you use an EHR, make sure your intake form integrates with the EHR's immunization tracking system.
You can include a separate section for "Maternal Family History" and "Paternal Family History" if you want to collect information about each side of the family separately.
Sensitivity: Be mindful of the sensitive nature of some of these questions, particularly drug and alcohol use. Assure patients of confidentiality.
Brevity: Keep the questions concise and easy to understand.
"Prefer not to say" option: Consider adding a "Prefer not to say" option for sensitive questions like drug and alcohol use. This allows patients to opt out without feeling pressured.

Instructions for IV. Review of Systems

Completeness: Ensure you cover all the major body systems.
Clarity: Use clear and simple language that patients can easily understand. Avoid medical jargon.
Conciseness: Keep the questions or checklist items brief and to the point.
"Other" Option: Including an "Other" option with a space to specify at the end of each system's questions or checklist is crucial. This allows patients to report less common or unusual symptoms.
Free-text at the end: Even with a checklist, consider having an overall free-text area at the end of the ROS section, such as: "Are there any other symptoms you are experiencing that we have not discussed?" This allows patients to add anything that might have been missed.
Digital Forms: If using digital forms, checkboxes are easy to implement. You can also use "branching logic" so that if a patient checks "yes" to a symptom, a free-text box appears for them to provide more details.

Instructions for V. Patient Authorization and Consent

Legal Counsel: It is essential to have your patient authorization and consent forms reviewed by legal counsel to ensure they are compliant with all applicable laws and regulations in your jurisdiction. Laws regarding consent, billing, and privacy can vary.
Clarity: Use plain language that patients can easily understand. Avoid legal jargon.
Comprehensiveness: Cover all necessary aspects of consent, and financial responsibility compliance.
Accessibility: Make sure the form is easy to read and understand. Consider offering it in multiple languages if your patient population requires it.
Separate Documents: While some of this information can be included on the intake form, it's often better to provide patients with separate, more detailed documents for things like your financial policies and your Notice of Privacy Practices. The intake form can then simply reference these documents.
Electronic Signatures: If using electronic forms, ensure your electronic signature process complies with relevant legal requirements.

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