Processing...
PATIENT INTAKE & HISTORY FORM
Date of Birth
*
For patient identification and record keeping.
Primary Complaint
*
Briefly describe the main reason for the visit.
Severity Rating
*
1
2
3
4
5
Rate the intensity of your primary complaint.
Current Medications
*
Required: List prescription and non-prescription drugs.
Allergies
*
Medications
Food
Environmental
None Known
Select all known allergy types.
Previous Surgeries
*
Yes
No
Have you had any major surgeries in the past 5 years?
Smoking Status
*
Never
Former
Current
Please indicate your current smoking status.
Submit