Templates
New Patient Intake
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New Patient Intake
Legal Full Name
*
Date of Birth
*
Gender Identity
Gender Identity
A
Male
B
Female
C
Non Binary
D
Prefer not to say
Do you need an interpreter?
*
Do you need an interpreter?
Yes
No
Contact Details
Mobile phone
Email address
Preferred contact method
*
Home address
Visit Details
Are you a new patient at this facility?
Yes
No
Primary reason for visit
Primary reason for visit
A
New problem / symptom
B
Follow-up
C
Annual / preventive
D
Procedure / surgery consult
E
Post-op follow-up
F
Second opinion
G
Other
Chief complaint
When did this start?
*
When did this start?
Today
< 1 week
1–4 weeks
1–6 months
6+ months
Pain level
*
Pain level
1
2
3
4
5
6
7
8
9
10
Symptoms
*
Symptoms
A
Pain
B
Swelling
C
Bleeding
D
Fever
E
Shortness of breath
F
Dizziness or fainting
G
Nausea or vomiting
H
Numbness or tingling
I
Weakness
J
Other
Urgency
*
Urgency
Routine (next available)
Soon (within 7 days)
Urgent (within 48 hours)
Availability
*
Availability
Weekdays Morning
Weekdays Afternoon
Weekdays Evening
Flexible
Emergency disclaimer acknowledgement
This form is not monitored in real time. If this is a medical emergency, I will call 911 or go to the nearest emergency room.
*
Untitled checkboxes field
I agree
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