TPC Medical Information Intake Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

First Name: *

Last Name:

Email Address *

Mobile phone number: *

Gender

Male

Female

CURRENT MEDICATIONS

Name of prescription and over the counter medications & dosage:

Do you take any:

Herbal Products

Vitamins

Minerals

Aspirin

ALLERGIES & REACTIONS

No know Allergies

LOCAL PHARMACY:

Drugs:

Food:

Other:

PAST MEDICAL & FAMILY HISTORY

Please check if you or your family members have had any of the following diseases

Diabetes:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

High Blood Pressure:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

High Cholesterol:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Heart Attack:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

TPC Medical Information Intake Form

Heart Disease:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Choose One

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Asthma/Emphysema:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Breast Cancer:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Colon Cancer:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Prostate Cancer:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Other Cancer:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Sickle Cell:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Tuberculosis:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Kidney/Bladder Problems:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Thyroid Disease:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Hepatitis or Jaundice:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Anemia:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Arthritis:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Positive HIV/AIDS:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Seizure Disorder:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

Other Illness:

Self

Father

Mother

Grandparent (Maternal)

Grandparent (Paternal)

Brother

Sister

TPC Medical Information Intake Form

PAST SURGERIES

Please list all past surgeries and the year performed

Appendix:

Gallbladder:

Thyroid:

Hysterectomy:

Hernia:

Heart:

Lung:

Tonsillectomy:

Other:

RECENT HOSPITALIZATIONS

(Other than above surgeries or child birth)

Please list year and reason:

Patient Name: *

Patient DOB: *

HEALTH MAINTENANCE

MEN:

Do you do self-testicular exams?

Yes

Date of last PSA:

WOMEN:

Date of last menstrual cycle:

Age of menopause:

Date of last pap smear:

Have you ever had an abnormal pap smear?

Yes

Pregnancies:

Total #

Deliveries:

Miscarriages:

Date of last mammogram:

Have you ever had a breast lump?

Yes

Do you do self breast exams?

Yes

Date of last Bone Density test:

ALL (Year of last) Colonoscopy (If over 50):

SOCIAL HISTORY

Marital Status:

Single

Married

Separated

Divorced

Widowed

Number of Children:

Employment:

Full-time

Part-time

Disabled

Retired

Unemployed

Occupation:

How often do you exercise

None

1-2 days/week

3-4 days/week

5+ days/week

Caffeinated Beverages: Cups/glasses per day:

TPC Medical Information Intake Form

TOBACCO & ALCOHOL HISTORY

Tobacco:

Do you use now?

Yes

Type:

Would you like to quit?

Yes

Have you used in the past?

Yes

How many years did you use?

When did you quit?

Alcohol:

How much alcohol do you drink?

None

Rarely

1-7 drinks/week

8-14 drinks/week

more than I4/week

Have you had a problem with alcohol in the past?

Yes

Recreational Drugs:

Do you currently use recreational drugs?

Yes

If so, type:

PERSONAL SAFETY

How often do you wear seatbelts?

Always

Often

Occasionally

Never

Do you have firearms in your home?

Yes

If yes, are they kept locked up?

Yes

Have you participated in any high risk behaviors that could put you at risk for HIV/AIDS such as: IV drug use, multiple sex partners or same sex partners?

Yes

TPC Medical Information Intake Form

VACCINATIONS/SKIN TEST

(Please enter information about vaccinations/skin tests you have received)

Tetanus Vaccine Flu:

Vaccine Pneumonia:

Pneumonia Vaccine:

TB Skin Test:

Ever had positive TB Skin Test?

Yes

Hepatitis B Vaccine:

Yes

Shingles Vaccine:

Yes

HPV Vaccine (Genital warts & Cervical Cancer vaccine)

Yes

Hepatitis A Vaccine

Yes

CONSTITUTIONAL

How do you feel in general?

IF YOU HAVE A LIVING WILL OR HEALTHCARE POWER OF ATTORNEY, PLEASE PROVIDE US WITH A COPY.

Please review to ensure the details are correct before completion.

Triad Primary Care

Triad Primary Care

TPC Medical Information Intake Form

Patient Information

CURRENT MEDICATIONS

ALLERGIES & REACTIONS

PAST MEDICAL & FAMILY HISTORY

TPC Medical Information Intake Form

TPC Medical Information Intake Form

PAST SURGERIES

RECENT HOSPITALIZATIONS

HEALTH MAINTENANCE

SOCIAL HISTORY

TPC Medical Information Intake Form

TOBACCO & ALCOHOL HISTORY

PERSONAL SAFETY

TPC Medical Information Intake Form

VACCINATIONS/SKIN TEST

CONSTITUTIONAL

Triad Primary Care

Triad Primary Care

TPC Medical Information Intake Form

Patient Information

CURRENT MEDICATIONS

ALLERGIES & REACTIONS

PAST MEDICAL & FAMILY HISTORY

TPC Medical Information Intake Form

TPC Medical Information Intake Form

PAST SURGERIES

RECENT HOSPITALIZATIONS

HEALTH MAINTENANCE

SOCIAL HISTORY

TPC Medical Information Intake Form

TOBACCO & ALCOHOL HISTORY

PERSONAL SAFETY

TPC Medical Information Intake Form

VACCINATIONS/SKIN TEST

CONSTITUTIONAL

Forms Sent!