General Intake form

The document is a patient intake form that collects essential information such as patient name, medical record number, date of birth, height, weight, blood pressure, pulse, and medical history including tobacco use and diabetes status. It also includes sections for medication allergies and a brief history of the injury or reason for the visit, along with details about the injured body part, duration of symptoms, and previous treatments. This form is designed to gather comprehensive information for medical assessment and treatment planning.

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General Intake form

Uploaded by

kb3367

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as DOCX, PDF, TXT or read online on Scribd

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Patient Name: ______ MRN:

Patient DOB: _//_____

Height: ___ Weight: BP: _ P: _____

Tobacco User? YES / NO

Diabetic? YES / NO If yes, Type 1 | Type 2

Medication Allergies __________________________________________________________________

Brief history of injury/reason patient is coming in for today:

Injured Body Part: L | R | BIL

Duration of Symptoms:

Previous Treatment:____________________________________________________________________

_____________________________________________________________________________________

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General Intake form

Uploaded by

General Intake form

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Patient Name: ______________________________ MRN: ________________________

Patient DOB: _______/________/___________

Height: _________ Weight: __________ BP: ___________ P: ___________

Tobacco User? YES / NO

Diabetic? YES / NO If yes, Type 1 | Type 2

Medication Allergies __________________________________________________________________

Brief history of injury/reason patient is coming in for today:

Injured Body Part: L | R | BIL

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Patient Name: ______ MRN:

Patient DOB: _//_____

Height: ___ Weight: BP: _ P: _____