Patient Intake Form
Please complete this form to help us understand your health history and current concerns. Your answers are confidential and will be used to support your care.
/10
Full legal name
/10
Date of birth
/10
Email address
Please enter a valid email format
/10
Phone number
Please enter a valid phone number
/10
Reason for today’s visit (please describe your main concern)
/10
How would you describe your current symptoms? (Select all that apply)
Pain
Fever/Chills
Cough/Shortness of breath
Nausea/Vomiting
Diarrhea/Constipation
Headache/Dizziness
Fatigue/Weakness
Rash/Skin changes
Anxiety/Depressed mood
Other
/10
Do you have any allergies?
No known allergies
Yes — medications
Yes — foods
Yes — environmental (pollen, pets, etc.)
Yes — latex
Not sure
/10
Please list any medications, vitamins, or supplements you currently take (include dose if known)
/10
Do you have any of the following medical conditions? (Select all that apply)
None
Asthma/COPD
Diabetes
High blood pressure
Heart disease
Kidney disease
Liver disease
Thyroid disorder
Cancer (current or past)
Depression/Anxiety
/10
Preferred pharmacy contact method
Call me
Text me
Email me
No preference
Thank you for completing the patient intake form.
If any of your symptoms are severe or worsening (e.g., trouble breathing, chest pain, fainting, severe bleeding), please seek emergency care immediately.
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