EmailMe Form - Patient Intake

Name

First Last

Phone

### - ### - ####

Age

Gender

Reason for Today's Visit

Check all that apply to you or your immediate family (parents, siblings, grandparents)

Check all symptoms you are currently experiencing

Please list any medication allergies that you have

Please list any medications you are currently taking

Are you currently pregnant, or is there a possibility that you are pregnant?

Yes

No

Are you currently using or do you have a history of tobacco use?

Yes

No

Are you currently using or do you have a history of illegal drug use?

Yes

No

Do you feel you are at risk for falls or falling injuries?

Yes

No

Please describe your alcohol consumption