Medical Intake Form



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How to write a Medical Intake Form? Download this Medical Intake Form template that will perfectly suit your needs.

Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Medical Intake Form template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!

Specifically, please place a check next to any of the following that you have had: Heart Disease Stroke Diabetes Hypertension Asthma Allergies Eczema Depression Sexually Transmitted Disease HIV / AIDS Tuberculosis (TB) Polio Cancer Major Trauma Page 2 of 6 Family History: Please Circle any of the following diseases tend to run in your family and list what relative (father, grandmother, etc.) Cancer: Heart Disease: Asthma: Stroke: Allergies: High Blood Pressure: Eczema: Seizures: Blood disorder: Diabetes: Social History: Please check beside any of the following you have used in the past or currently: Tobacco (cigarettes, cigar, pipe) Tobacco (chewing) Coffee Herbal Products Alcohol (beer, wine or spirits) Illegal Drugs Birth Control Pills Vitamins / Supplements Medications: List all of the Prescription Medicines or Over the Counter Drugs you are now taking: Allergies: Please list any medications to which you are allergic: Please list any foods that you are allergic or sensitive: Food Cravings: Please list any strong food cravings or favorite foods: Please list any strong food aversion or foods you avoid:

This Medical Intake Form is intuitive, ready-to-use and structured in a smart way. Try it now and let this Medical Intake Form sample inspire you.

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