Nurse Intake Form
Date________________
Name_________________________________________ Age_____________ Date of birth_____________
Reason for visit: ___________________________________________________________________________
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Any new medical illnesses or operations since your last visit: ______________________________________
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Are you currently using any tobacco products: ______Yes
______No
Have you had any recent problems with: (if yes, please INDICATE AND EXPLAIN.)
o
o
o
o
o
o
o
o
o
o
Problems with bleeding, healing, or scarring:_________________________________________________
Hay fever, rash, or immunosuppression:____________________________________________________
Fever, chills, night sweats, or unintentional weight loss:_________________________________________
Sore throat, blurry vision, or chest pain:_____________________________________________________
Abdominal pain, bloody stool, or bloody urine:_______________________________________________
Joint aches, muscle weakness, or neck stiffness:_______________________________________________
Thyroid problems:_____________________________________________________________________
Headaches or seizures:_________________________________________________________________
Cough, shortness of breath, or wheezing:____________________________________________________
Anxiety or depression:__________________________________________________________________
Allergies □ None
□ Latex
□ Medications (list below)
__________________________________________________________________________________________
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Do you take:
Aspirin □Y □N
Ibuprofen □Y □N Coumadin (warfarin)□Y □N Plavix □Y □N
Please list all new prescription drugs, dietary supplements, nonprescription and herbal products:
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Any additional information you would like the doctor to know about: _______________________________
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For office use only:
ROOM: ___________
CHIEF COMPLAINT _______________________________________________________________________________
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CURRENT MEDICATIONS__________________________________________________________________________
__________________________________________________________________________________________________
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PHYSICIAN NOTES________________________________________________________________________
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Complete skin exam
Waist up exam
Head and Neck exam
Focused exam
FOLLOW UP:______________________________________________________________________________
BP _______/________ Pulse _____ __
NEW MEDICATIONS
RR _________ Height _________ Weight _________
PHARMACY:______________________________