INTAKE FORM DOB AGE DATE / / First MI Last How would you like to be addressed? Gender: Female Male Primary Care Name Address Telephone number Pharmacy Name Address Telephone number Reason for visit: If the reason for your visit is a STUDY, please initial the following statement: I am currently not participating in any other clinical trials at other locations MEDICAL HISTORY AND REVIEW OF SYMPTOMS Date First Date Taking Office Use Only Condition When? Diagnosed Resolved Medication? Dermatological (Skin) None  Precancer/Cancer Now the past In  Rash Now the past In  Abnormal mole Now the past In  Other skin conditions: Now the past In  Neurological (Nervous system) None  Migraines / Headaches Now the past In  Depression Now the past In  Anxiety Now the past In  Psychiatric Care/ Hospitalization Now the past In  Epilepsy/Seizures Now the past In  Other: Now the past In  Cardiovascular (Heart & blood) None  Murmur Now the past In  Irregular Heart Rate/Palpitations Now the past In  Chest Pain Now the past In  Heart Attack Now the past In  High Blood Pressure Now the past In  Elevated Cholesterol Now the past In  Other: Now the past In  Pulmonary (Lungs) None 
INTAKE FORM First MI Last DOB AGE DATE / / How would you like to be addressed? Gender: Female Male Primary Care Pharmacy Name Address Telephone number Name Address Telephone number Reason for visit: If the reason for your visit is a STUDY, please initial the following statement: I am currently not participating in any other clinical trials at other locations MEDICAL HISTORY AND REVIEW OF SYMPTOMS Condition When? Date First Diagnosed Date Resolved Taking Medication? Office Use Only Dermatological (Skin) None  Precancer/Cancer Now In the past  Rash Now In the past  Abnormal mole Now In the past  Other skin conditions: Now In the past  Neurological (Nervous system) None  Migraines / Headaches Now In the past  Depression Now In the past  Anxiety Now In the past  Psychiatric Care/ Hospitalization Now In the past  Epilepsy/Seizures Now In the past  Other: Now In the past  Cardiovascular (Heart & blood) None  Murmur Now In the past  Irregular Heart Rate/Palpitations Now In the past  Chest Pain Now In the past  Heart Attack Now In the past  High Blood Pressure Now In the past  Elevated Cholesterol Now In the past  Other: Now In the past  Pulmonary (Lungs) None 
clinic_patient_registration_packet_2018.docx