INITIAL INTAKE FORM
BASIC
Full Legal Name (required)
Preferred Name/Alias
Maiden Name
Date of Birth (required)
Email (required)
Street Address (required)
City (required)
State (required)
Zip Code
Social Security Number
Phone (Cell) (required)
Phone (Alternate)
Health Insurance? (required) YesNo
Medicaid or Medicare? (required) YesNo
Primary Insurance Company
ID Policy Number
Group Number
Secondary Insurance Company (if applicable)
Secondary ID Policy Number
Secondary Group Number
DETAILS
Gender (required) ---FemaleMaleTransgenderOther
Race (required) ---American Indian or Alaskan NativeAsianBlack or African AmericanHispanicNative Hawaiian or other Pacific IslanderOtherWhiteDecline to Specify
Ethnicity (required) ---Not Hispanic or LatinoHispanic: Mexican AmericanHispanic: Puerto RicanHispanic: CubanHispanic: or LatinoDecline to Specify
Preferred Language (required) ---EnglishFrenchItalianJapanesePortugueseRussianSign LanguageSpanishOtherDeclined to Specify
English Proficient? YesNo
HOUSEHOLD Living Arrangement (required) ---Private ResidenceOther IndependentHomelessFoster FamilyOther
# Adults
# Children
Pregnant? (required) YesNo
Marital Status (required) ---AnnulledDivorcedDomestic PartnersMarriedNever MarriedMinorSeparatedWidowed
Employment Status (required) ---EmployedUnemployedRetiredPart-TimeStudentMinor
Disabilities? NoneHearingVisualAmbulatoryOther (please explain) Comments
Smoker? (required) YesNo
Frequency
Veteran? (required) YesNo
Highest Level Education Completed (required) ---Bachelors DegreeCompleted High School/GEDGraduate Degree or HigherLess than 12th GradeLess than 9th GradeLess than 6th GradeSome College
Emergency Contact (required)
Relationship (required)
Emergency Phone (required)
Preferred Hospital
Family/Preferred Physician
Physician Office Name
Physician Phone
Attorney/Referral Source Name
Phone
Fax
Street Address
City
State
Within the last 12 months, have you been treated or diagnosed with any of the following (select all that apply and explain) (required):
SeizuresDiabetesHigh Blood PressureHeart DiseaseBipolarDepressionBowel ProblemsSchizophreniaUlcersHepatitisCirrhosisChest PainCancerShortness of Breath Infectious DiseasesLiver ProblemsKidney ProblemsLung ProblemsAbscessSerious Infections PancreatitisHead InjurySurgeryBroken BonesTBHIVSTD'sPsychiatric Hospitalization Suicide AttemptsAddictionsEating DisordersVisual Impairments Hearing Impairments Speech ImpairmentsThreatened/Harmed OthersOther (please explain)None
Comments
Do you have any allergies? (required) YesNo
Date of last physical exam (required)
Please list any over the counter and/or prescribed medications that you may be taking or prescribed and not taking (please include medication name, dosage, instructions & reason for and duration of a prescription) (required)
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