This section captures the essential demographic and contact details for the patient.
Full Legal Name
Date of Birth
Biological Sex
Legal Gender
Preferred Pronouns
Street Address
City/Town
State/Province
Postal/Zip Code
Country
Primary Phone
Secondary Phone
Email Address
Preferred Language
Marital Status
This contact should be someone who is not the patient and can be reached in case of an emergency.
Full Name
Relationship to Patient
Primary Phone
Secondary Phone
What is the main reason you are seeing the provider today?
When did this symptom/problem first begin?
Is the problem getting better, worse, or staying the same?
Better (Improving)
Staying the same (Stable)
Worse (Declining)
Not sure / Not applicable
Please describe any pain (scale 1-10, 10 being the worst):
Specific Body Area Affected (if applicable):
Please include all prescription medications, over-the-counter medications, vitamins, and supplements.
Medication Name | Dosage/Strength | Frequency | Reason for Taking | ||
|---|---|---|---|---|---|
1 | |||||
2 | |||||
3 | |||||
4 | |||||
5 |
Allergen (Medication, Food, Environmental, etc.) | Type of Reaction (e.g., Rash, Swelling, Anaphylaxis) | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Please check the box if you have been diagnosed with or treated for any of the following conditions:
Condition | Yes | Condition | Yes | |
|---|---|---|---|---|
High Blood Pressure (Hypertension) | Diabetes | |||
High Cholesterol | Heart Disease | |||
Asthma/COPD | Arthritis | |||
Cancer | Stroke/TIA | |||
Thyroid Disorder | Depression/Anxiety | |||
Digestive Issues | Kidney Disease |
Previous Surgeries/Hospitalizations
Procedure/Reason | Date (Approx.) | ||
|---|---|---|---|
1 | |||
2 |
Occupation
Smoking Status
Alcohol Consumption
Recreational Drug Use
Dietary Habits (e.g., Vegetarian, Standard, Low-Sugar)
Exercise Routine (Type and Frequency)
Do you live alone?
Indicate if any immediate blood relatives (Parents, Siblings, Children) have or had the following:
Condition | Relationship(s) (e.g., Mother, Brother) | ||
|---|---|---|---|
1 | Heart Disease/Stroke | ||
2 | Cancer | ||
3 | Diabetes | ||
4 | High Blood Pressure | ||
5 | Kidney Disease |
I acknowledge that I have been informed of my rights and responsibilities as a patient of this practice.
Signature:
I consent to the examination, diagnostic procedures, and medical treatment considered necessary by the attending healthcare provider.
Signature:
Appointment Date/Time:
Provider Seen:
Form Reviewed By:
Patient ID: