Patient Intake Form

Patient Information

First Name

Last Name

Email

Address

City

State

Zip Code

Mobile Phone

Last 4 Digits of Social Security Number

Date of Birth

Gender

Race/Ethnic Group

Marrital Status

Height

Weight

Occupation

Employer

Emergency Contact Name

Emergency Contact Phone

Primary Doctor Name

By providing the name of the doctor, I authorize the release of healthcare documents to them.

Primary Doctor Phone

Insurance

Primary Insurance Company Name

Primary Policy Number

Primary Group Number

Primary Insurance - Name of Policy Holder

Primary Insurance - Date of Birth of Policy Holder

Secondary Insurance Company Name

Secondary Policy Number

Secondary Group Number

Secondary Insurance Name of Policy Holder

Secondary Insurance Date of Birth of Policy Holder

Attach a copy of your insurance card (front and back).

Health Condition

Primary Complaint

Secondary Complaint

Cause of Complaint - Other

Pain Level Now

No Pain (1) TO Severe Pain (10)

Pain Level at its Worst

No Pain (1) TO Severe Pain (10)

When did the condition begin?

What percentage of the day does it bother you?

When does it bother you the most?

Is it affecting daily or recreational activities?

Is it affecting daily or recreational activities?

What worsens the condition?

What offers relief to the condition?

Symptoms

General

Muscle & Joints

Gastro Intestinal

Cardio-Vascular

Eye/Ear/Nose/Throat

Genito-Urinary

Skin or Allergies

Respiratory

Medication and Supplements

List of Medications and Supplements

01. Name of Drug/Supplement

01. Dosage

01. Frequency

01. Comments

02. Name of Drug/Supplement

02. Dosage

02. Frequency

02. Comments

03. Name of Drug/Supplement

03. Dosage

03. Frequency

03. Comments

04. Name of Drug/Supplement

04. Dosage

04. Frequency

04. Comments

05. Name of Drug/Supplement

05. Dosage

05. Frequency

05. Comments

06. Name of Drug/Supplement

06. Dosage

06. Frequency

06. Comments

Women's Health

Are you pregnant?

When are you due?

Are you planning on getting pregnant?

When did you get your last period?

When was your last PAP Smear?

Have you experienced any of the items below?

General & Family Health History

Provide dates and descriptions of any surgeries, major accidents, hospitalizations and allergies.

Experienced Diseases

Experienced Diseases - Other

Do you smoke?

How often do you smoke?

Do you drink alcohol?

How often do you drink alcohol?

Which of the items below is in your dad's health history?

Which of the items below is in your mom's health history?

Which of the items below is in your siblings' health history?

Comments on your or your family's health history?

Please tell us of any infomation not captured above.

Please upload any files that you want to have the practitioner review during your visit.

Signature

All the information provided on the forms is accurate. I have read and reviewed the following policies by Skyline Wellness on their website (link provided below) or they have been provided to me by the Skyline Wellness staff.

I hereby sign all the aforementioned documents and attest that all the included information is true and correct to the best of my knowledge. I choose to decline receipt of my clinical summary after every visit. Clinical summary of your visit will be provided upon request only.

Patient First Name

Patient Last Name

Attach a copy of your driver's license to keep in your file.

You will have to provide a copy of an official ID to confirm your identification.