MEDICAL INTAKE FORM


Client Name: Age: Height: Weight:

Which hand do you use to write?


PCP:  

Are your immunizations up-to-date? 

 
Do you exercise?   

If yes, please describe:


Tobacco:

If yes, # of cigarettes/day: # of years: Last use?  

Alcohol:

If yes, frequency? Last use?  

Marijuana:

If yes, frequency? Last use?  

Drug use:

If yes, frequency? Last use?  

Are you pregnant? 

Is it possible you could be pregnant?


MEDICAL HISTORY – Please check current or previous medical conditions.

Head injury with loss of consciousness?

If yes, when?  
Head injury without loss of consciousness?    

If yes, when?  


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:

Musculoskeletal:

Neurological/Psychiatric:

Endocrine/Hematologic:

Anesthesia problems:

Cancer:

Musculoskeletal:


REVIEW OF SYSTEMS – Please check if you have current symptoms or medical problems in the following areas.
Constitutional

 

Ears, Nose, Throat

 

Heart

Respiratory

 

GI

 

Skeletal

 

Skin  

 

Neurological 

 

Psychiatric

 

Endocrine 

 

Hematology  

 

Pain Do you have pain?

If yes, pain location:   

Pain Intensity – Please elect the number, or range of numbers, that best describes the intensity of your pain.

Mild                                        Moderate                                            Severe                                    Worst pain imaginable


ALLERGIES 


MEDICATIONS – Please list the medications you are taking below.
Medication:                                            Prescriber:                            Frequency:                         Dose:             Start Date
 
 
 
 
 
 
 
 
 
 

Leave this empty:

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Document name: MEDICAL INTAKE FORM
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May 11, 2020 10:03 am PDTMEDICAL INTAKE FORM Uploaded by Adam Falk - adam.falk@options.org IP 50.240.25.195
May 11, 2020 11:38 am PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
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May 11, 2020 11:42 am PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
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May 11, 2020 12:36 pm PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 11, 2020 12:38 pm PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195