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MEDICAL INTAKE FORM

Options Location:

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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Timestamp

Audit

May 11, 2020 10:03 am PST

MEDICAL INTAKE FORM Uploaded by Adam Falk - adam.falk@options.org IP 69.1.101.108

May 11, 2020 11:38 am PST