MEDICAL INTAKE FORM
Options Location:Options Counseling and Family Services Location: Beaverton - 8285 SW Nimbus Ave, Ste 148; Beaverton, OR 97008 Fax: (503)352-3262Clackamas - 12901 SE 97th Ave, Ste 340; Clackamas, OR 97015 Fax: (503)655-6806Eugene - 1255 Pearl St, Ste 102; Eugene, OR 97401 Fax: (541)687-2063Florence - 1445 8th St; Florence, OR 97439 Fax: (541)997-8606Multnomah - 11010 SE Division St, Ste 202; Portland, OR 97266 Fax: (503)335-5974Newport - 119 NE 4th St; Newport, OR 97365 Fax: (541)264-7515North Salem - 2645 Portland Road NE, Ste 120; Salem, OR 97301 Fax: (503)393-3135Roseburg - 283 SE Fowler St, Ste 2; Roseburg, OR 97470 Fax: (541)464-6457South Salem - 1515 Liberty St SE; Salem, OR 97302 Fax: (503)468-3130Springfield - 175 West B St, Bldg D; Springfield, OR 97477 Fax: (541)762-1974St. Helens - 445 Port Ave, Ste C; St. Helens, OR 97051 Fax: (503)335-5974Woodburn - 1320 Meridian Dr; Woodburn, OR 97071 Fax: (503)498-5810
Client Name: Age: Height: Weight: Date of Birth:Which hand do you use to write? LeftRight
PCP: Are your immunizations up-to-date? NoYes Do you exercise? NoYes If yes, please describe:
Tobacco: NoYes If yes, # of cigarettes/day: # of years: Last use? Alcohol: NoYes If yes, frequency? Last use?
Marijuana: NoYes If yes, frequency? Last use?
Drug use: NoYes If yes, frequency? Last use?
Are you pregnant? NoYes Is it possible you could be pregnant? NoYes
MEDICAL HISTORY - Please check current or previous medical conditions. Anemia Asthma Blood clots Thyroid Anxiety Diabetes Frequent UTI Fibromyalgia Heart attack Emboli Alcoholism Depression Emphysema Liver Disease Arthritis HIV Heart disease Cancer MRSA infection Osteoporosis Kidney Disease Gout Neuropathy High cholesterol Rheumatoid arthritis RSD/CRPS High blood pressure Sexual Dysfunction Stroke/Seizure Substance abuse Psychiatric illness Ulcers/Wounds Irregular heartbeat Sleep Apnea
Head injury with loss of consciousness? YesNo If yes, when? Head injury without loss of consciousness? YesNo If yes, when? Other
PAST SURGICAL HISTORY - Please list any previous surgical procedures, the date, and location.
Procedure: Date: Location
FAMILY HISTORY – Please check medical conditions that are present in your family history.Cardiac: Heart attack Irregular heartbeat Sudden death Musculoskeletal: Arthritis Rheumatoid disease Neurological/Psychiatric: Seizures Stroke Depression Psychosis Endocrine/Hematologic: Thyroid Diabetes Bleeding/clots Anesthesia problems: No Yes Cancer: No Yes Musculoskeletal: Arthritis Rheumatoid disease
REVIEW OF SYSTEMS – Please check if you have current symptoms or medical problems in the following areas. Constitutional None Weight loss Weight gain Insomnia Chronic Fatigue Other
Ears, Nose, Throat None Loss of Hearing Seasonal Allergies Sinus Pain Ringing in Ears Other:
Heart None Chest Pain Hypertension Edema Palpitations High Cholesterol Other:
Respiratory None Asthma Wheezing Frequent Cough Other:
GI None Heartburn/Indigestion Ulcer Abdominal Pain Stomach Bleed Other
Skeletal None Arthritis Muscle Weakness Joint Pain Back Pain Other:
Skin None Rash Ulcers Scars Other :
Neurological None Headaches Seizures Numbness Dizziness Other:
Psychiatric None Depression Mood Swings Anxiety Other:
Endocrine None Diabetes Hypothyroid Hyperthyroid Hot Flashes Other
Hematology None Easy Bruising Bleeding Anemia Other:
Pain Do you have pain? No Yes If yes, pain location:
Pain Intensity - Please elect the number, or range of numbers, that best describes the intensity of your pain. 0........ 1........ 2........ 3........ 4........ 5........ 6........ 7........ 8........ 9........ 10........ Mild Moderate Severe Worst pain imaginable
ALLERGIES None Penicillin Sulfa Latex Other:
MEDICATIONS - Please list the medications you are taking below. Medication: Prescriber: Frequency: Dose: Start Date
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Document Name: MEDICAL INTAKE FORM
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