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 
Persistent Now In the past  Other: Now In the past  Gastrointestinal (Digestion) None  Ulcers Now In the past  Hepatitis / Problems Now In the past  Gall Bladder Disease Now In the past  Heartburn/GERD Now In the past  Chronic Constipation Now In the past  Diarrhea Now In the past  Persistent Nausea Vomiting  Now In the past  Blood in Stool Now In the past  Other: Now In the past  Urologic (Kidneys & Bladder) None  Frequent Urinary Infection Now In the past  Kidney Infection Now In the past  Kidney Disease Now In the past  Bladder Problems Incontinence (leaking) Urinary Frequency Urinary Urgency Now In the past  Now In the past  Now In the past  Blood in Urine Now In the past  Other: Now In the past  Musculoskeletal(Muscles& None  Osteoporosis Osteopenia  Now In the past  Arthritis: Type Now In the past  Fibromyalgia Now In the past  Fractures Now In the past  Other: Now In the past  Eyes, Ear, Nose, Throat None  Glaucoma -Type Now In the past  Hearing Problems Now In the past  Seasonal Allergies/Hay Fever Now In the past  Cataracts Now In the past  Other eye problems: Now In the past  Current dental issues? Yes No  Other: Now In the past  Endocrine (Glands) None  Diabetes Mellitus: Type I or II Now In the past  Thyroid Disease Now In the past  Other: Now In the past  Hematology Disorders) None  Anemia Now In the past  Clots / Pulmonary Embolism Now In the past  Other: Now In the past  Lupus/ SLE Now In the past  Cancer None 
GYNECOLOGICAL HISTORY Last Menstrual Period: Method of Birth Control: Age of 1st menstrual period: Menses last days and come every days : heavy medium light Last Pap: If any abnormal paps, when and how was it treated: Last mammogram: Where: Any abnormal mammograms and when: Breast procedures/ Ultrasound/ MRI? Breast Implants? Type: Lifetime sexual partners 1-5 6-20 > 20 Condition When? Date First Diagnosed Date Resolved Taking Medication? Office Use Only Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Uterine fibroids Now In the past  Ovarian Cyst Now In the past  Vaginal Dryness Now In the past  Decreased Sex Drive Now In the past  Painful intercourse Now In the past  Irregular Bleeding Now In the past  Painful Periods Now In the past  Other: Now In the past  MALES: Condition When? Date Diagnosed Date Resolved Taking Medication? Office Use Only Reproductive None  Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Other: Prostate Problems Now In the past  Decreased Sex Drive Now In the past  Erectile Dysfunction Now In the past  Other: Now In the past  Patient Signature Date Reviewed by Provider Date Reviewed by CRC (if applicable) Date