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Patient Intake Form
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Patient Intake Form
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You can download the PDF Patient Intake Form from
here
or you can fill and submit it below:
Patient Information:
*Name
Address
State
*Phone Number
Occupation:
Today's Date
City
Zip Code
Date of Birth
Sex
--- Select ---
Male
Female
*Email
In case of emergency, please contact:
*Name
*Phone Number
Relation
Medical History:
Height:
Weight:
BMI:
Do you have any medication or food allergies? Yes / No If Yes, please list (including reaction):
Are you pregnant or breastfeeding?
--- Select ---
Yes
No
Have you ever been told that you have an electrolyte imbalance or other abnormal labs?
(Please check all that apply)
Hypermagnesemia (High magnesium levels)
Hypercalcemia (High calcium levels)
Hypokalemia (Low potassium levels)
Hemochromatosis (High iron levels)
Date of last chemistry screen or other lab testing
Are you a diabetic?
--- Select ---
Yes
No
Are you a smoker?
--- Select ---
Yes
No
If Yes, how much do you smoke?
How many alcoholic drinks do you consume in a week?
--- Select ---
0
1
2
3
4
5
6
7
8
9
10+
Do you use any recreational drugs?
--- Select ---
Yes
No
If Yes, which ones and how often?
Please list everything you are currently taking: Prescription Medications – Strength – Frequency-Condition being treated
Over the Counter Drugs – Strength – Frequency – Condition being treated
Vitamins and Other Supplements – Strength – Frequency – Condition being treated
MEDICAL HISTORY CONTINUED:
Do you take Digoxin (Lanoxin) for a heart problem?
--- Select ---
Yes
No
Do you take any diuretics or water pills?
--- Select ---
Yes
No
If Yes, please list
Do you take any steroids, i.e. Prednisone?
--- Select ---
Yes
No
If Yes, please list
Do you have any of the following conditions?
(Please check all that apply)
History of pancreatitis
Kidney Disease/Kidney Insufficiency
Stomach problems (semaglutide may exacerbate symptoms)
Personal or family history of Medullary Thyroid Carcinoma (MTC)***
Personal or family history of Multiple Endocrine Neoplasia type 2 (MEN)***
Taking any other diabetic related medications Yes_____ No _____***
Depression or Suicidal thoughts ***
List any other medical conditions you have (not mentioned above):
List of all surgical procedures you’ve had with approximate dates:
Is there anything else you’d like the nurse and physician to know?
Submit Form
