Concierge Medicine Intake Form

The Concierge Medicine Intake Form is designed for concierge medicine practices and direct primary care programs, capturing the thorough health assessment data needed to deliver personalized, proactive care. This template goes beyond standard intake forms to collect patient demographics alongside a comprehensive medical history, detailed family history with multi-generational disease mapping, wellness and longevity goals, lifestyle assessment (nutrition, exercise, sleep, stress management, alcohol and tobacco use), preventive screening history, and care experience preferences. The form reflects the premium, whole-person approach that distinguishes concierge medicine from volume-based primary care.

Built for concierge medicine practices, executive health and wellness programs, direct primary care clinics, and longevity-focused medical practices, this form includes sections for current health concerns prioritized by the patient, complete medication and supplement list, specialist and subspecialist provider directory, mental health and cognitive wellness screening, sexual and reproductive health, travel schedule and immunization needs, health technology usage (wearable devices, health apps, genetic testing services), advance care planning, communication preferences (phone, text, email, patient portal), and scheduling preferences for the annual comprehensive physical examination.

All fields are HIPAA-compliant and crafted to set the tone for a high-touch, patient-centered practice. The comprehensive pre-visit form demonstrates the thoroughness of concierge care from the first interaction, allowing patients to reflect on their health goals and priorities before meeting their physician. This detailed baseline enables the concierge physician to create a truly individualized health optimization plan, coordinate with specialists proactively, and identify risk factors for early intervention rather than reactive disease management.