Medical Intake Form

Save, fill-In The Blanks, Print, Done!

Click on image to zoom / Click button below to see more images
Adobe Acrobat (.pdf)

  • This Document Has Been Certified by a Professional
  • 100% customizable
  • This is a digital download (19.8 kB)
  • Language: English
  • We recommend downloading this file onto your computer.

ABT template rating: 8

Malware- and virusfree. Scanned by: Norton safe website

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.

We certainly encourage you to download this Medical Intake Form now and use it to your advantage!

Also interested in other health and healthcare templates? AllBusinessTemplates is the most elaborate platform for downloading health templates and is updated every day with new health and healthcare related templates! Just search via our search bar or browse through our thousands of free and premium health forms and templates, contract, documents, letters, which are used by professionals in the healthcare industry. For example health care directive, mental health treatment plan, health management report, allergy log, healthy weekly meal plans, sick leave letter, health evaluation form, and much more...

Nothing on this site shall be considered legal advice and no attorney-client relationship is established.

Leave a Reply. If you have any questions or remarks, feel free to post them below.

default user img

We generate fears while we sit. We over come them by action. Fear is natures way of warning us to get busy. | Dr. Henry Link