Medical Intake Form Template

About you

This helps us reach you and keep your records straight. Everything you tell us stays confidential.

Patient intake form

Please answer what you can. If a question does not apply to you, leave it blank - your clinician will go through it with you.

Patient name

Completed by

Email address

Phone number

Home address

Date of birth

Place of birth

Has anything changed recently that affects your health?0 / 500 characters

Tuberculosis

A short set of questions we ask everyone.

When were you last tested for TB?

What was the result?

Have you ever had a positive TB test?

YesNoNot sure

Are you having any of these at the moment?

A cough lasting more than three weeksLosing weight without tryingCoughing up bloodHeavy night sweats

Have you been in close contact with anyone who has TB?

YesNoNot sure

Vaccinations

Did you have your childhood vaccinations?

YesNoI do not know

Allergies

Do you have any allergies?

YesNo

What are you allergic to, and what happens?0 / 500 characters

Are you allergic to any medication?

YesNo

Which medicines, and what happens?0 / 500 characters

Sexual health

Answer only what you are comfortable answering.

Have you ever been diagnosed with a sexually transmitted infection?

YesNoPrefer not to say

Medical history

Mark anything that applies. If you are unsure about a line, leave it - we will talk it through.

As far as you know, has anyone in your family had a significant illness?

YesNoI do not know

If yes, who and what?0 / 500 characters

Hormones and metabolism

Condition	In the past	Ongoing	Never
Type 1 diabetes
Type 2 diabetes
Low blood sugar
Pre-diabetes
Underactive thyroid
Overactive thyroid
Polycystic ovary syndrome
Difficulty conceiving
Weight gain
Weight loss
Eating disorder

Anything else in your medical history we should know about?0 / 500 characters

Mental health

These questions are here because your mind and body affect each other. Answer what you can.

Have you experienced any of these?

Any serious physical injuries in your past?0 / 500 characters

Anything difficult in your life you would like us to know about? 0 / 500 characters

Reproductive health

Skip any part of this that does not apply to you.

Have you had any of these during a pregnancy?

Pre-eclampsiaDepression after birthGestational diabetesA baby over 8 pounds

Dental and medication

What medication are you taking at the moment?0 / 500 characters

Any vitamins, supplements or herbal remedies?0 / 500 characters

The answers I have given are accurate as far as I know, and I agree to my information being handled as set out in the Privacy Notice.

Vaccine	Yes	No	Not sure
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Flu
Pneumonia (Pneumovax)
Chickenpox (Varivax)
Shingles (Zostavax)
Meningitis

Test	Yes	No	Not sure
Cervical smear
Anal smear
HIV test
Hepatitis C test

Operation	Yes	No	Not sure
Appendix removed
Breast lumpectomy
Facial surgery
Hysterectomy
Phalloplasty

Condition	In the past	Ongoing	Never
Irritable bowel syndrome
Crohn's disease
Ulcerative colitis
Peptic ulcer
Acid reflux
Coeliac disease

Condition	In the past	Ongoing	Never
Heart attack
Other heart disease
Stroke
High cholesterol
Irregular heartbeat
High blood pressure
Rheumatic fever
Mitral valve prolapse

Condition	In the past	Ongoing	Never
Kidney stones
Gout
Interstitial cystitis
Frequent urine infections
Frequent thrush
Erectile dysfunction
Other sexual difficulty

Condition	In the past	Ongoing	Never
Chronic fatigue syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus
Immune deficiency
Serious infection

Condition	In the past	Ongoing	Never
Asthma
Long-term sinus trouble
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep apnoea

Condition	In the past	Ongoing	Never
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADHD
Autism
Memory problems
Dementia
Parkinson's disease
Multiple sclerosis
Seizures

Method	Using now	Used before	Never
The pill
Hormonal patch
Vaginal ring
Condoms
Diaphragm
Hormonal coil
Copper coil
Partner's vasectomy

Medicine	Regularly	In the past	Rarely	Never
Anti-inflammatories (ibuprofen, aspirin)
Paracetamol
Antacids and acid blockers
Antibiotics
Steroids
The contraceptive pill

Condition	In the past	Ongoing	Never
Eczema
Psoriasis
Acne
Melanoma
Other skin cancer