Medical Intake Form

Gather a new patient's full history in one form. It spans personal details, tuberculosis screening, vaccinations, allergies, sexual health, family and surgical history, specialty histories, medications and supplements.

Use this template

In the Claude connectors directory

Patient Name

First Name

Last Name

Person completing this form (if not the patient)

First Name

Last Name

Relationship to the Patient

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of Birth

Place of Birth

Gender

Marital Status

Did something trigger your change in health?

Date of your last tuberculosis test

Test Result

Have you ever tested positive for tuberculosis?

Yes No

If yes, did you complete at least 6 months of preventive treatment?

Yes No

Are you experiencing any of these symptoms?

Cough lasting more than 3 weeks Night sweats Unexplained weight loss Fever Coughing up blood None

Have you been in contact with someone with TB disease?

Yes No Not sure

Did you receive your childhood vaccinations?

Yes No Not sure

Do you have any allergies?

Yes No

Please list your allergies

Do you have any drug allergies?

Yes No

Please list your drug allergies

Sexual Orientation

Have you ever been diagnosed with a sexually transmitted infection?

Yes No

Have any blood relatives had the conditions below?

Yes No Not sure

Significant physical trauma you have experienced

Emotional trauma you have experienced

Gynecological History

Gynecological Conditions

Abnormal Pap test Polycystic ovary syndrome Uterine fibroids Infertility Current contraception use None

Men's Health History

Dental History

Regular check-ups Gum disease Tooth sensitivity Dentures Orthodontic treatment None

Current Medications

Supplements

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