Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Infectious Disease Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Referring Physician
Presenting Infection & Symptoms
Symptom Timeline
Travel History
Exposure Risk Assessment
Immunization Records
Additional details
Immune Status Evaluation
Prior Culture & Sensitivity Results
Current Antimicrobial Therapy
Antimicrobial Allergy History
| Allergy | Reaction |
|---|---|
TB Screening History
Surgical & Device History
Please bring to your visit: lab & imaging
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Pharmacy Information
Consent & Signature
Date
Infectious Disease Intake Form template from formisoft.com. formisoft.com/intake-templates/infectious-disease-intake