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Medical Intake Template 1 -Form Fill
Q1
First Name
Name
Q2
Last Name
Name
Q3
First Name
Person Filling Out This Form (if not the Patient)
Q4
Last Name
Person Filling Out This Form (if not the Patient)
Q5
Email
Q6
Phone Number
Q7
Street Address
Address
Q8
Street Address Line 2
Address
Q9
City
Address
Q10
State / Province
Address
Q11
Postal / Zip Code
Address
Q12
Date of Birth
Q13
Place of Birth
Q14
Gender
Please Select
Male
Female
Q15
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Q16
Did something trigger your change in health?
Q17
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Q18
When was the last time you had a test for Tuberculosis?
Date
Q19
What was the result?
Q20
Have you ever had a positive test for Tuberculosis?
Yes
Unsure
No
Q21
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
Q22
Have you had known contact with someone known to have TB disease?
Yes
No
Q23
Did you receive your childhood vaccinations?
Yes
No
Unknown
Q24
Do you have any allergies?
Yes
No
Q25
Do you have any drug allergies?
Yes
No
Q26
What is your sexuality?
Lesbian
Gay
Bisexual
Queer
Heterosexual
N/A
Other
Q27
Have you had tests below?
Yes
No
Unsure
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test
Q28
Have you ever been diagnosed with or tested positive for a sexually transmitted infection?
Yes
No
Q29
To your knowledge, have any of your blood relatives had any of the following section?
None
Unknown
Yes
Q30
Surgical History
Yes
No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty
Q31
Gastroenterology Related Medical History
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Q32
Cardiology Related Medical History
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Q33
Endocrine Related Medical History
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Q34
Nephrology Related Medical History cont.
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Q35
Orthopedics Related Medical History cont.
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Q36
Immune System Related Medical History cont.
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Q37
Lung Related Medical History
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Q38
Cancer History
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Q39
Cancer History Cont.
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Q40
Mental Health Condition History
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Q41
Please list any significant physical trauma you've experienced
Q42
Please list emotional trauma you've experienced in your life
Q43
Gynecological History
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
Q44
Gynecological History cont.
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
Q45
Gynecological History cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Q46
Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Q47
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
Q48
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Q49
Medication history
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Q50
Medications
Q51
Supplements
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