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
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?
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).
Chronic Conditions: Please select any conditions you have or for which you have received treatment.
Diabetes (Type I or II)
Hypertension (High Blood Pressure)
Heart Disease/Arrhythmia
Asthma/Respiratory Issues
Thyroid Disorders
Autoimmune Conditions
Cancer
Surgical History: Please list any major surgeries and the approximate dates.
Type of Surgery | Approximate Date | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Hospitalizations: Have you been hospitalized for any non-surgical reasons in the last 5 years?
Current Medications: Please list all prescription drugs, dosages, and frequency.
Medicine Name | Dosage | Frequency | ||
|---|---|---|---|---|
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 | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Allergies (Environmental/Food): List any known allergies to foods or environmental factors.
Allergen | Allergic Reaction | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Indicate if an immediate family member (parents, siblings, grandparents) has a history of:
Heart Disease/Stroke
Cancer
Diabetes
Mental Health Disorders (Depression, Anxiety, Bipolar)
Genetic Disorders
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?
Check any symptoms you have experienced frequently in the last 3 months:
Neurological: Headaches, dizziness, numbness, or tingling.
Digestive: Bloating, constipation, diarrhea, or heartburn.
Musculoskeletal: Joint pain, stiffness, or muscle weakness.
Mental Health: Persistent low mood, panic attacks, or difficulty concentrating.
Skin: Rashes, unusual moles, or excessive dryness.
Preferred Pharmacy: (Name and Location)
Primary Care Provider: (Name and Clinic)
Communication Preference: How do you prefer to receive appointment reminders?
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
Please remove this form template insights section before publishing.
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.
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.
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.
The Lifestyle & Wellness section shifts the form from "reactive" (fixing a problem) to "proactive" (maintaining health).
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.
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.
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
Please remove this mandatory questions recommendation before publishing.