patients Intake Form

MyHealth LLC

14502 Greenview Dr #500 L21, Laurel, Maryland, 20708

301-728-3574

PATIENT INTAKE FORM

Patient's Information

First Name

Middle Name

Last Name

Date of Birth

Marital Status

Legal Sex

Gender Identity

Language

Race

Ethnicity

Email address

Address

Address 2

City/State

Zip Code

Home Phone

Mobile Phone

May we text you?

Yes

Health History

Do you have any food, drugs or any other allergies?

Yes

Please list all the medications you are taking. Include prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.

Past Psychiatric/Medical History (check all that apply)

Anxiety Disorder

Panic Disorder

Asthma

Diabetes

Hypertension

Other

Past Surgical History

Social & Family History

Social History

Education

Marital Status

Exercise

Family History

For each family member, select their relation and any applicable health problems.

Relation

Health Problems (check all that apply)

Alcoholism

Depression

Heart disease

Cancer

Substance use problems

Hypertension

Diabetes

Stroke

MyHealth LLC

PATIENT INTAKE FORM

Constitutional

Allergic/Immunologic

Eyes

Genitourinary

Respiratory

Neurological

Psychiatric

Integumentary (Skin)