Medical Patient Intake Assessment
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone
Email
Address
Emergency Contact
Name
Phone
Relationship
Medical History
Primary Physician
Current Medications
Allergies
Past Illnesses / Surgeries
Family Medical History
Current Symptoms / Reason for Visit
Describe your current symptoms or reason for your visit
How long have you been experiencing these symptoms?
Severity (e.g. mild, moderate, severe)