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New Patient intake form

Every office has a different intake form but most will be similar in the sense that they want to gather patient information like: patient's name, address, contact info, reasons for visit, medications currently taking, and/or any medical history regarding past symptoms.

Time to complete

2 minutes

Eligibility

If you are 18 years old or older and you are seeking mental health services through our organization you are eligible to fill out our New Patient intake form.

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Questions for New Patient intake form

1.

Name

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Marital Status

The answer should be a single choice:
  1. Single
  2. Married
  3. In a domestic partnership
  4. Divorced
  5. Widowed
4.

Education

The answer should be a single choice:
  1. Less than a high school diploma
  2. High school degree or equivalent
  3. Bachelor's degree
  4. Master's degree
  5. Doctorate
5.

Occupation

The answer should be a single choice:
  1. Upper Management
  2. Trained Professional
  3. Middle Management
  4. Skilled Laborer
  5. Junior Management
  6. Consultant
  7. Administrative
  8. Staff
  9. Temporary Employee
  10. Support Staff
  11. Researcher
  12. Student
  13. Self-employed/Partner
  14. Other
6.

Contact number

The answer should be a phone number.
7.

Contact Email

The answer should be an email input.
8.

Address

The answer should be a text input.
9.

Emergency Contact Number

The answer should be a phone number.
10.

Emergency contact person name

The answer should be a text input.
11.

Have you EVER had any of the following (Select all that applicable)

The answer should be a single (or) multiple choice by row and column:
Arthritis
Asthma/Breathing Problems
Bleeding/Clotting Disorder
Blood Pressure Disorder
Bowel/Stomach Problems
Cholesterol Disorder
Cancer
Eye Disorder
Heart Disease/Disorder
Lung Disorder
Liver Disease
Seizure or Epilepsy
Thyroid Disorder
Urinary/Kidney Disorder
Psychiatric Disorder/Illness
* Check all that apply
12.

Please list any other medical illnesses or problems what is not listed above

The answer should be a text input.
13.

Reason for Medical visit

The answer should be a text input.
14.

Please indicate ALL that you have experienced within 24 hrs. 

The answer should be a multiple choice:
  1. Fever
  2. Fatigue
  3. Chills
  4. Sweats
  5. Chest Pain
  6. Red Eyes
  7. Runny Nose
  8. Nosebleed
  9. Itchy Eyes
  10. Flu-Like Symptoms
  11. Sore Throat
  12. Shortness of Breath
  13. Cough
  14. Chest Congestion
  15. Wheezing
  16. Abdominal Pain
  17. Vomiting
  18. Nausea
  19. Constipation
  20. Diarrhoea
  21. Headache
  22. Dizziness
  23. Seizures
  24. Excessive Thirst
  25. Heat Intolerance
  26. Cold Intolerance
  27. Depression
  28. Anxiety

Similar Ideas

  • New Patient Information Form
  • Patient Health History Form
  • Patient Consent Form
  • Patient Financial Responsibility Form
  • Patient Insurance Information Form

Here are some FAQs and additional information
on
New Patient intake form

What is the patient intake form?

Patient intake forms are designed to expedite the paperwork process for new and existing patients at medical practices. Improving the patient intake process frees up time in the day for additional appointments and reduces stress on front desk staff.

Why are patient intake forms important?

Intake Form is the best way to digest and understand your client, know what needs to be modified, and if you need to refer them to a medical practitioner before you work with them. Naturally, divulging this kind of information can be difficult for some people.

What is an Online patient intake form?

Online intake forms are a great way to collect and store patient information without any of the hassles of paperwork. With the right HIPAA-compliant tools, they're quick and easy to put together, allowing you to design infinitely modifiable templates for all of your counseling services.

What should an Intake form include?

Identification data like name, date of birth, phone numbers, and emergency contact information. No financial information should be kept in the dental record. It should include systemic diseases, allergies, reactions to anesthetics, current medications and treatment, herbal supplements, surgeries, injuries, and diet.

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