Patient Information Form

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Patient Information Form
--- Provided by Intake Solutions, Inc. ---

Instructions:	Please use this online form to update your patient information. 1. Pre-fill the form after entering your Verification Info. 2. Make changes as needed. 3. 'Report & Save' your data in a printable report format.

Verification Info:	(Use to pre-fill this form with existing patient data.)
To view patient info:	Lname, Initials (Doe, JA): DOB (mmdd):
To add/change info:	Mother's Maiden Name: ==>
Last updated:	03/29/2017

Name (Doe, John A.):	DOB: (mm/dd/yyyy)

General Info:	(If yes to any item, please explain.)
Under a physician's care now?	(name, tel, etc)
Ever hospitalized or had major operation?
Ever had serious head or neck injury?
Taking any medications, pills, or drugs?
Ever taken Phen-Fen or Redux?
Ever taken bisphosphonate meds?	(Fosamax, etc)
Do you use controlled substances?
Are you on a special diet?
Do you use tobacco?

Women only:	Pregnant or trying?	Nursing?	On the pill?

Allergic to:	Aspirin Metal	Penicillin Latex	Codeine Sulfa Drugs	Acrylic Local Anesthetics
Any others?:

Afflictions: (Do you have, or have you had, any of these?)	AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blis Congenital Heart Dis Convulsions Cortisone Medicine	Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Disease Hemophilia Hepatitis A	Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitrial Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis	Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumers or Growths Ulcers Venereal Disease Yellow Jaundice
Any others?:

Comments:	First paragraph of a comment. Second paragraph of a comment.

Disclaimer: Intake Solutions provides this service for your convenience; we pledge not to sell or release any patient data without explicit patient permission; we will store your data securely. However, Intake Solutions assumes no responsibility if patient data is improperly revealed. It is the responsibility of patients and providers to KEEP THIS DATA SECURE FROM PRYING EYES!!!