Health Records Intake Form

First Name:

Middle Name:

Last Name:

Preferred method of communication for patient reminders

Test Email Call

Cell #:

Email address:

Date of Birth:

Gender:

Male Female

Preferred Language:

Smoking Status:

Every Day Smoker Occasional Smoker Former Smoker Never Smoked

Smoking Start Date (Optional):

CMS requires providers to report both race and ethnicity

Race:

American Indian or Alaska Native Asian Black or African American White (Caucasian) Native Hawalian or Pacific Islander I Decline to Answer

Ethnicity:

Hispanic or Latino Not Hispanic or Latino I Decline to Answer

(Please include regularly used over the counter medications)

If Yes, please list regularly used over the counter medications (continue on back if needed):

Height:

Weight:

Blood Pressure:

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