Appointment Intake Questionnaire Screening Form

Today’s Date

Current MD

PATIENT INFORMATION & APPOINTMENT REQUEST

Patient’s Last Name

First

Middle

Date of Birth

Age

Sex

Male Female

Street Address

City

State

Zip

Telephone

Insurance Company

Do You Have a HMO Insurance

Yes No

If Yes, Are you with Lake County Physician Association or Advocate Condell?

Yes No

Group Number

Member ID

Effective Date

Name of Plan

How Did You Hear About Us?

Do you have any family members that are a current patient of Orchard Medical Center?

Yes No

If so, who?

What Do You Need An Appointment For?

When Were You Seen By Your Current MD Last?

CURRENT MEDICATIONS

List ANY Over The Counter Supplements You Are Taking Including Strength and Duration

List ANY Prescribed Medications You Are Taking Including Strength and Duration

1

Reason

2

Reason

3

Reason

4

Reason

5

Reason

6

Reason

7

Reason

LIST ANY RECENT VISIT TO HOSPITAL, ER, ACUTE CARE CENTER, TAKE CARE CLINIC, WALK-IN CLINIC

#1 Name of Facilty

Reason for Visit

Location of Facility You Received Care

Do You Have Paperwork From Your Visit?

Yes No

#2 Name of Facilty

Reason for Visit

Location of Facility You Received Care

Do You Have Paperwork From Your Visit?

Yes No

#3 Name of Facilty

Reason for Visit

Location of Facility You Received Care

Do You Have Paperwork From Your Visit?

Yes No

Currently Under the Care of:

#1 Name of MD

Reason for Care

#2 Name of MD

Reason for Care

#3 Name of MD

Reason for Care

Patient Signature

Date