/Templates/New Patient Intake

New Patient Intake

Legal Full NameRequired

Date of BirthRequired

Gender Identity

AMale

BFemale

CNon Binary

DPrefer not to say

Do you need an interpreter?Required

Yes

No

Contact Details

Mobile phone

Email address

Preferred contact methodRequired

Home address

Visit Details

Are you a new patient at this facility?

Primary reason for visit

ANew problem / symptom

BProcedure / surgery consult

CFollow-up

DPost-op follow-up

EAnnual / preventive

FSecond opinion

GOther

Chief complaint

When did this start?Required

Today

< 1 week

1–4 weeks

1–6 months

6+ months

Pain levelRequired

1

2

3

4

5

6

7

8

9

10

SymptomsRequired

APain

BFever

CNausea or vomiting

DSwelling

EShortness of breath

FNumbness or tingling

GBleeding

HDizziness or fainting

IWeakness

JOther

UrgencyRequired

Routine (next available)

Soon (within 7 days)

Urgent (within 48 hours)

AvailabilityRequired

Weekdays Morning

Weekdays Afternoon

Weekdays Evening

Flexible

Emergency disclaimer acknowledgement

This form is not monitored in real time. If this is a medical emergency, I will call 911 or go to the nearest emergency room.

I agreeRequired