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Medical Intake Form Template

Streamline Patient Onboarding with Our Medical Intake Form

Gathering patient information can be overwhelming, but this medical intake form template simplifies the process for healthcare providers. Designed for clinics and practices, it helps you collect essential data about a patient's medical history, medications, and allergies, ensuring a comprehensive database from the start. This template not only enhances patient experience with user-friendly design but also organizes crucial data needed for effective treatment, boosts practice efficiency, and minimizes errors in patient information. Experience a seamless intake process with this ready-to-use template.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Email address
Mobile phone number
Street address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone number
Insurance provider
Member ID
Primary reason for today's visit
Current pain level
No pain
Mild
Moderate
Severe
Not applicable
If other conditions, please list
List any past surgeries or hospitalizations with dates (if any)
Do you currently have or have you ever been diagnosed with any of the following?
List all current medications and supplements with doses and frequency (if none, write 'None')
List any drug, food, or environmental allergies and reactions (if none, write 'None')
Tobacco use
Never
Former
Current some days
Current every day
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Are you currently pregnant or breastfeeding?
Yes
No
Not applicable
Prefer not to say
Preferred contact method
Phone
Email
Text message
No preference
I consent to treatment and acknowledge the practice's privacy policies
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I authorize the practice to release necessary information to my insurer for payment
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Typed signature (enter your full name)
Date
I consent to receive text messages for appointment-related notifications
Yes
No
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Paper art illustration featuring a medical intake form with lines and checkboxes for patient information.

When to use this form

Use this form when you onboard new or returning patients in clinics, telehealth, urgent care, or rehab. It helps your front desk collect essentials before the visit, so check-in is faster and errors drop. For demographic and contact details, pair it with the Patient demographic information form. To capture conditions, surgeries, and family history, add the Medical history form. Specialists can route cases, verify medications, and flag allergies before the patient arrives. Small practices gain a complete chart on day one; large teams get consistent data across locations. The result: cleaner records, safer decisions, and less time spent calling patients for missing info.

Must Ask Medical Intake Questions

  1. What is the main reason for your visit today, and when did symptoms start?

    This helps you triage, schedule, and route the case to the right clinician fast. Clear timing guides urgency and sets expectations for testing or follow-up.

  2. Do you have any chronic conditions or past surgeries and hospitalizations?

    Baseline risks shape treatment choices and prevent complications. Pairing this with the Medical summary form gives clinicians a quick snapshot before they walk in.

  3. Which medications and supplements do you take, and do you have any drug or food allergies?

    Accurate lists help you avoid interactions and adverse reactions. They also speed medication reconciliation in your EHR.

  4. Who is your primary care or referring doctor, and how can we contact them?

    Coordinating with current providers reduces duplicate tests and gaps in care. The Doctor information form keeps names, specialties, and contacts standardized.

  5. What is your insurance information, and do you consent to treatment and our privacy policy?

    Collecting this upfront prevents billing delays and ensures compliance. Clear consent also builds trust and documents your legal basis to provide care.

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