Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

Patient Information

First name

Last name

Date of birth

Age

Home phone number

Cell phone number

Best Email address to reach you at

Personal information may be sent to you here, although encrypted

Gender/Identity

Male Female Other

Marital Status

Single

Married

Divorced

Common-Law

Number of Children

Occupation

Employer

Address

Best way to Contact you:

Text Msg, Whatsapp, Email, Cell, Home Phone

Emergency Contact:

How did you hear of our clinic? Who can we thank for the referral?

Medical History

Prostate Enlargement or Other Prostate related Issues

Have you received a Blood transfusion after March 2021?

Yes No

Please state the details regarding your transfusion:

Please mention the date, reason, quantity received, and location.

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Date of your last physical exam

Can't Remember?

Unsure Never

Is there a chance that you are pregnant?

Yes No Unsure

Date of Last Menstrual Period

Past Surgeries / Previous Hopitalizations/ Procedures

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Please include any herbs or Supplements that you take (prescribed or otherwise).

Do you have any allergies to medications?

If so, please list the medication(s) and the type of reaction.

Have you ever tested positive for Covid-19?

Yes No

Approximately when did you test positive for Covid-19?

Enter all dates if you tested positive more than once, and any other information you deem pertinent.

Have you been vaccinated for Covid-19?

Yes No

If yes, please specify approximate dates, and Make of Vaccine and any reactions

Do you live with anyone or are you in close daily contact with anyone that has received the Covid-19 Vaccine? Eg: Family members, children, spouse, intimate partner, daily coworkers

Yes

If Yes, please specify:

Have you received a Tetanus shot in the past 10 years?

Yes No Unsure

Have you ever been immunized against Hepatitis A?

Yes No Unsure

Have you ever been immunized against Hepatitis B?

Yes No Unsure

If you are over the age of 65 years, have you ever received a Pneumococcal vaccine?

Yes No Unsure

Family History:

Do you have a parent, brother or sister with a history of the following:

Heart attacks before the age of 55

Diabetes

High blood pressure

Thyroid disease

Glaucoma

Sickle cell

Colon Cancer

Relation

Males

Prostate cancer

Females

Breast Cancer

Ovarian cancer

Uterine cancer

Preventative Care:

Have you ever had a Colonoscopy

Yes No

How often do you do Self- Breast exams?

Less than Monthly Monthly Never

Have you ever had a mammogram done?

Yes No

If yes, were the results Normal?

When was your last Pap smear? Were the Results normal?

Social History:

Have you ever used Tobacco/Cigarettes?

Yes No

Do you still smoke?

Yes No

Smoking History

Previous Smoking History

Do you Vape?

Yes No

If so, how much, and how often, on average?

Do you drink Alcohol?

Yes No

If so, how much, and how often, on average?

Drug History

Have you ever used any recreational drugs?

Yes

If yes, which substances have you used? (Check all that apply)

Cannabis (Marijuana)

Cocaine

Ecstasy (MDMA)

LSD (Acid)

Psilocybin (Mushrooms)

Methamphetamines

Heroin

Prescription Medications (Misused)

Other

How frequently do you use these substances?

When was your last use?

Preferred method of use?

Smoking

Vaping

Snorting

Injection

Oral (Pills, Edibles)

Other

Do You Exercise regularly?

Yes No

If so, what activities and how often?

Sleep Patterns

Average hours per night?

Quality

Good

Fair

Poor

Please describe the reason for your visit today.

List any symptoms you experience, and any information you think relevant.

Mark the areas on the image where you are experiencing symptoms- (If applicable)

If you have any copies of previous tests, please attach and upload them here

Add file

Please upload a file

Date

Your information will be encrypted.