Patient Form

Patient Information/Intake Form

Date
Patient Name
Patient DOB: (MM/DD/YYYY)
SS #/SIN
Gender
Home phone
Cell phone
E-Mail Address
Select Appropriate
Address
Address
City
State
Zip
City
Preferred language:
Ethnicity:
Race:
Main complaint
Patient’s or parent/guardian’s employer
Work phone
Spouse or parent/guardian’s name
Home phone
Cell phone
How did you hear about us?
Person to contact in case of an emergency
Phone
In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence.
Parent or Guardian:
Date:
Responsible Party
Name of The Person responsible for this account:
Relationship to Patient
Birthdate
Insurance ID
Insurance group No.
Home Phone
Cell Phone
Do you have any additional insurance?
If yes, complete the following:
Name of the insured:
Relationship to patient:
Relationship to patient:
Insurance Company
Home Phone
Cell Phone
Consent to Email, Call or Text message for Appointment Reminders and Other Healthcare Communications:

Patients in our practice may be contacted via phone/text message to be reminded of an appointment, to obtain feedback on an experience with on our office, and to provide general health reminders/information. If you would like to receive this feature in the future, please read the consent below and sign.

I consent to receive text messages and/or emails from Ogden Wellness Center at my cell phone and any number forwarded to transferred to that number. The cell phone number and email address that I authorize to receive text messages or email for appointment reminders, feedback and general health reminders/information is:

Carrier
Email
I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing
Patient e-Signature
Date
Referred by
1. Past Health History:

​​​​​​​Surgeries:
Date
Type of Surgery
Date
Type of Surgery
Date
Type of Surgery
A. Previous Injury or Trauma:
- Have you ever broken any bones? Which?
B. Allergies
2. Family Health History:
Do you have a family history of? (Please indicate all that apply)
Other
A. Deaths in immediate family:
Cause of parents’ or siblings’ death
Age at death
Cause of parents’ or siblings’ death
Age at death
Cause of parents’ or siblings’ death
Age at death
3. Social and Occupational History:​​​​​​​
A. Job description:
B. Recreational activities:
C. Lifestyle
- Hobbies
- Level of Exercise
- Alcohol Use
- Tobacco Use
- Drug Use
- Diet
4. Medications
Medication
Reason for taking
Medication
Reason for taking
Medication
Reason for taking
Helpful Articles
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