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Client Intake Form

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PATIENT INFORMATION

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Gender
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Your Address*
Preferred Contact Method
Relationship to Patient
REASON FOR VISIT
Have you been treated for this before?
MEDICAL HISTORY SUMMARY
Do you have any of the following conditions? (Check all that apply)
Are you currently taking any medications?
Do you have any allergies?
Have you had any surgeries or hospitalizations?
LIFESTYLE & SOCIAL HISTORY
Do you smoke or use tobacco products?
Do you consume alcohol?
Do you use recreational drugs?
Do you have any concerns about access to healthcare, transportation, or financial barriers?
PHARMACY INFORMATION
CONSENT AND SIGNATURE
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