Patient Intake Form Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Sex(Required) Male Female DOB(Required) Month Day Year Height(Required)Weight(Required)Past Medical History Add RemoveList Any Pre-existing conditions you may have. ex. Hypertension, diabetes, high cholesterol, etc Surgical History Add RemoveList any surgical procedures you have undergone.Drink Alcohol?(Required) Yes No Use Illegal Drugs?(Required) Yes No Smoke Cigarettes?(Required) Yes No How much/week?How much alcohol do you drink a week?Please list any illegal drugs you take Add RemoveHow many packs/day?How many cigarette packs do you smoke in a day?AllergiesMedications/Vitamins/Supplements Add RemovePlease list all medications you take, including Over-the Counter Medications, along with dose and frequencyHave you ever been diagnosed with cancer?(Required) Yes No Are you taking steroids?(Required) Yes No Are you pregnant?(Required) Yes No Are you Breastfeading?(Required) Yes No Are you on Blood Thinners?(Required) Yes No Aspirin, Coumadin, Plavix, Eliquis, etcAre you taking any NSAIDS?(Required) Yes No Motrin, Advil, Aleve, Ibuprofen, etcWho is your Primary Care Provider?(Required)How did you hear about us?internetfriendphysiciansocial mediaother
