Sunshine Health Care Center
Patient Medical Intake Form

Instructions:

Please fill out the following form and all of its sections as completely and thoroughly as you can before your first visit. Items with an asterisk (*) are required. Though most items are not technically required to submit this form, it helps your doctor give you the best possible care when you complete the entire intake. If information is missing or incorrect, your appointment could be delayed while we ask you to correct it. Please allow at least 20 - 30 minutes to fill in this form. Currently you cannot save this information and come back to it.
Tip: If you need extra time, first write your essay answers in Notepad (or any text editor), then copy-and-paste when you are ready to submit the form.

Privacy Disclaimer:

The information provided in this form is private and confidential between you and your Doctor, unless you submit a signed release form to give us permission to provide this information to a 3rd party. The information here is transferred across our network using SSL encryption, and is stored electronically with an extra layer of encryption to comply with HIPAA standards.

Problems?

If you have a problem with this form, please contact us and let us know your specific error. You may download the pdf version below, print and fill out the form by hand.
Download printable intake form (pdf)

Personal Information

Date of Birth:




May we leave phone messages relating to your visits?

Emergency Contact:


Relationship Status:


Live With:


Family Physician:

Specialists Involved in Care:


Context of Care

Successful health care and preventive medicine are only possible when the physician understands the patient physically, mentally and emotionally. Your time, thoughtfulness and honesty in completing this overview will greatly improve our ability to help with your health needs.

What is your present level of commitment to address any underlying causes of your signs and symptoms that may relate to your lifestyle? Rate from 1 to 10, 10 being 100% committed.

Health Overview

Wellness is a balancing of many factors. Please select your level of overall satisfaction, with 10 being the most satisfied and 1 being the least satisfied.

1 2 3 4 5 6 7 8 9 10

How would you describe your general health?

Medical History

Allergies / Hypersensitivities (separate with a comma):


Do you get regular screening tests done by another doctor (Pap, blood tests, etc.)?


Which medications, either by prescription or over the counter, are you taking or have you taken in the past 6 months?

Do you wear any of the following?


Family History:
Do you have a family history of any of the following diseases or conditions? When answering, include your parents, brother/sisters, and grandparents, if known.

Review of Systems

For the following conditions / symptoms, please choose either Yes, No, Sometimes or Past (if the situation previously applied to you).

General

  • Do you sleep well?
  • Average 6-8 hours?
  • Have a supportive relationship?
  • Have a history of abuse?
  • Experienced a major trauma?
  • Drug/alcohol dependence?
  • Use alcoholic beverages?
  • Use tobacco?
  • Do you enjoy your work?
  • Take vacations?
  • Spend time outside?
  • Exercise daily?
  • Eat three meals a day?

Neurologic

  • Seizures?
  • Muscle weakness?
  • Loss of memory?
  • Vertigo or dizziness?
  • Paralysis?
  • Numbness or tingling?
  • Easily stressed?
  • Loss of balance?

Endocrine

  • Hypothyroid?
  • Hypoglycemia?
  • Excessive thirst?
  • Fatigue?
  • Heat or cold intolerance?
  • Hyperthyroid?
  • Diabetes?
  • Excessive hunger?
  • Seasonal depression?
  • Difficulty losing weight?

Immune

  • Chronically swollen glands?
  • Slow wound healing?
  • Chronic fatigue syndrome?
  • Chronic infections?
  • Night sweats?

Head

  • Headaches?
  • Migraines?
  • Head injury?
  • Jaw or TMJ problems?

Ears

  • Impaired hearing?
  • Ringing in ears?
  • Dizziness?
  • Earaches?

Eyes

  • Impaired vision?
  • Cataracts?
  • Glaucoma?
  • Spots in vision?
  • Color blindness?
  • Tearing or dryness?
  • Eye pain or strain?

Nose and Sinus

  • Frequent colds?
  • Stuffiness?
  • Sinus Problems?
  • Nose bleeds?
  • Hayfever?
  • Loss of smell?

Mouth and throat

  • Frequent sore throat?
  • Copious saliva?
  • Sore tongue or lips?
  • Hoarseness?
  • Teeth grinding?
  • Gum problems?
  • Dental cavities?

Neck

  • Lumps in neck?
  • Goiter?
  • Difficulty swallowing?
  • Pain or stiffness in neck?

Skin

  • Rashes?
  • Acne/boils?
  • Change in skin color?
  • Skin lumps or bumps?
  • Eczema or hives?
  • Itching?
  • Perpetual hair loss?

Respiratory

  • Cough?
  • Sputum?
  • Asthma?
  • Wheezing?
  • Bronchitis?
  • Coughing up blood?
  • Shortness of breath?
  • Painful breathing?
  • Emphysema?
  • Tuberculosis?
  • Shortness of breath lying down?

Gastrointestinal

  • Trouble swallowing?
  • Change in thirst?
  • Change in appetite?
  • Nausea/vomiting?
  • Ulcer?
  • Jaundice?
  • Gall bladder disease?
  • Liver disease?
  • Hemorrhoids?
  • Pancreatitis?
  • Heartburn?
  • Abdominal pain, cramps?
  • Belching or passing gas?
  • Constipation?
  • Blood in stools?
  • Black stools?

Mental Emotional

  • Treated for emotional problems?
  • Depression?
  • Anxiety or nervousness?
  • Poor concentration?
  • Mood swings?
  • Considered suicide?
  • Tension?
  • Memory problems?

Urinary

  • Increased frequency of urination?
  • Inability to hold urine?
  • Pain in urination?
  • Frequency at night?
  • Frequent urinary infections?
  • Kidney stones?

Musculoskeletal

  • Joint pain or stiffness?
  • Arthritis?
  • Broken bones?
  • Weakness?
  • Muscle spasms or cramps?
  • Sciatica?

Blood

  • Anemia?
  • Easy bleeding or bruising?
  • Cold hands/feet?
  • Deep leg pain?
  • Thrombophlebitis?
  • Varicose veins?

Cardiovascular

  • Palpitations?
  • Chest Pain?
  • Murmurs?
  • Heart Attack?
  • Rheumatic Fever?
  • Edema?
  • High Blood Pressure?
  • Arrhythmias?
  • Low Blood Pressure?

Sexual Health

  • Are you sexually active?
  • Birth control?
  • STD prevention?
  • Sexually transmitted infections?

Female Reproductive (disregard if male)

  • Are your cycles regular?
  • Painful menses?
  • Heavy or excessive flow?
  • PMS?
  • Bleeding between cycles?
  • Clotting?
  • Endometriosis?
  • Ovarian cysts?
  • Vaginal odor?
  • Vaginal discharge?
  • Abnormal pap?
  • Pain during intercourse?
  • Difficulty conceiving?
  • Do you do self breast exams?
  • Breast pain/tenderness?
  • Breast lumps?
  • Nipple discharge?
  • Menopausal symptoms?

Male Reproductive (disregard if female)

  • Discharge or sores?
  • Testicular masses?
  • Testicular pain?
  • Do you do self testicular exams?
  • Prostate disease?
  • Erectile dysfunction?
  • Premature ejaculation?
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