Patient Intake

Patient First Name

Patient Last Name

Preferred Name

Patient Gender

Patient DOB

Medicare Number

Address

Relationship Status

Number of Children

Mobile Phone

Email Address

Preferred method of contact/confirmation

Do you currently work

YesNo

Occupation

Do you have private health cover?

YesNo

Who is your health cover provider?

Medical History

Are you currently taking medications?

YesNo

Please list medications

Do you have any allergies?

YesNo

Please list allergies

How many times a week do you exercise?

How long is each exercise session?

Do you smoke?

YesNo

Do you regularly drink alcohol?

YesNo

Please list any prior surgeries

Is there anything else we should know? If so, please describe

Assignment and Release

I, the undersigned, certify that I (or my dependent) understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be confidential to my treating doctor. I am aware of the limits of confidentiality. It is my responsibility to inform this office of any changes in my mental health status.

Signature

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Name

Date