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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
Do you need an interpreter?
No
Contact Details
Mobile phone
Email address
Preferred contact method
*
Home address
Visit Details
Are you a new patient at this facility?
Do you need an interpreter?
Yes
Do you need an interpreter?
No
Primary reason for visit
Primary reason for visit
A
New problem / symptom
Primary reason for visit
B
Follow-up
Primary reason for visit
C
Annual / preventive
Primary reason for visit
D
Procedure / surgery consult
Primary reason for visit
E
Post-op follow-up
Primary reason for visit
F
Second opinion
Primary reason for visit
G
Other
Chief complaint
When did this start?
*
When did this start?
Today
When did this start?
< 1 week
When did this start?
1–4 weeks
When did this start?
1–6 months
When did this start?
6+ months
Pain level
*
Pain level
1
Pain level
2
Pain level
3
Pain level
4
Pain level
5
Pain level
6
Pain level
7
Pain level
8
Pain level
9
Pain level
10
Symptoms
*
Symptoms
A
Pain
Symptoms
B
Swelling
Symptoms
C
Bleeding
Symptoms
D
Fever
Symptoms
E
Shortness of breath
Symptoms
F
Dizziness or fainting
Symptoms
G
Nausea or vomiting
Symptoms
H
Numbness or tingling
Symptoms
I
Weakness
Symptoms
J
Other
Urgency
*
Urgency
Routine (next available)
Urgency
Soon (within 7 days)
Urgency
Urgent (within 48 hours)
Availability
*
Availability
Weekdays Morning
Availability
Weekdays Afternoon
Availability
Weekdays Evening
Availability
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
Submit
