Mental Health Intake Form
Specialized intake for behavioral health and therapy practices. Includes mood assessment (PHQ-9/GAD-7 style), treatment history, substance use screening, safety assessment, and therapy goals.
New Patient Intake Form
Comprehensive intake form with demographics, insurance, medical history, and consent. The most popular template for primary care, specialty clinics, and multi-provider practices.
Pediatric Intake Form
Child-specific intake form with developmental milestones, immunization records, birth history, school information, and parent/guardian details. Designed for pediatric and family medicine practices.
Acupuncture Intake Form
Acupuncture-specific intake covering chief complaint, TCM constitution assessment, pain mapping, lifestyle and emotional health, and treatment history. For licensed acupuncturists and integrative medicine clinics.
Addiction Medicine Intake Form
Addiction medicine intake covering substance use history, withdrawal risk assessment, medication-assisted treatment screening, mental health comorbidities, recovery support systems, and treatment readiness. For addiction medicine practices and MAT programs.
Allergy & Immunology Intake Form
Allergy and immunology intake with detailed allergy history, environmental triggers, reaction severity, immunodeficiency screening, and medication/immunotherapy history. For allergists and immunologists.
Annual Wellness Visit Form
Pre-visit form for annual physicals and wellness exams. Covers health changes since last visit, preventive screenings due, vaccination history, and current health goals.
Bariatric Surgery Intake Form
Bariatric surgery-specific intake covering weight history, BMI documentation, obesity-related comorbidities, prior weight loss attempts, nutritional assessment, and psychological readiness screening. For bariatric surgery programs and metabolic centers.
Behavioral Health Intake Form
Behavioral health intake covering presenting concerns, substance use screening, trauma history, psychosocial assessment, and treatment readiness. For behavioral health agencies, community mental health centers, and outpatient counseling practices.
Cardiology Intake Form
Cardiology-specific intake covering cardiac symptoms, chest pain assessment, heart disease risk factors, and cardiovascular history. Designed for cardiologists, electrophysiologists, and heart failure clinics.
Chiropractic Intake Form
Chiropractic-specific intake covering spinal complaints, pain patterns, lifestyle factors, previous chiropractic care, and X-ray/imaging history. Built for chiropractic and wellness practices.
Concierge Medicine Intake Form
Concierge medicine intake covering comprehensive health history, wellness goals, executive health screening, lifestyle assessment, family medical history, and care preferences. For concierge practices, direct primary care, and executive wellness programs.
Corporate Wellness Screening Form
Corporate wellness screening form for employers, occupational health providers, and workplace wellness programs. Captures employee demographics, biometric measurements, health risk factors, lifestyle assessment, medical conditions checklist, and participation consent.
Dental Patient Intake Form
Dental-specific intake covering oral health history, dental anxiety assessment, previous dental work, TMJ symptoms, and dental insurance verification. For general dentistry, orthodontics, and oral surgery.
Dermatology Intake Form
Dermatology-specific intake with skin concern history, sun exposure assessment, skin cancer screening questions, cosmetic treatment history, and photo upload for lesion documentation.
Endocrinology Intake Form
Endocrinology-specific intake covering diabetes management, thyroid disorders, hormonal symptoms, metabolic screening, and endocrine medication history. For endocrinologists and diabetes care centers.
ENT (Ear, Nose & Throat) Intake Form
ENT-specific intake covering hearing loss, sinus symptoms, throat complaints, balance disorders, and allergy history. For otolaryngologists, audiologists, and head and neck surgery practices.
Fertility Clinic Intake Form
Fertility clinic-specific intake covering reproductive history, menstrual cycle documentation, prior fertility treatments, partner information, and psychosocial screening. For reproductive endocrinology, IVF centers, and fertility practices.
Follow-Up Visit Form
Short pre-visit form for return patients. Captures treatment progress, symptom changes, medication updates, and new concerns since the last appointment.
Functional Medicine Intake Form
A comprehensive functional medicine patient intake form for integrative and holistic health practices, capturing health timeline, environmental exposures, diet and nutrition, supplements, sleep and stress assessment, gut health, and toxin exposure history.
Gastroenterology Intake Form
GI-specific intake covering digestive symptoms, bowel habit assessment, prior endoscopic procedures, liver and pancreatic history, and dietary factors. For gastroenterologists and hepatology practices.
Genetic Counseling Intake Form
Comprehensive intake form for genetic counseling appointments capturing family history, hereditary conditions, and reasons for genetic consultation. Designed for genetics clinics, prenatal counseling centers, and oncology genetic services.
Geriatrics Intake Form
Geriatrics-specific intake covering functional assessment, fall risk screening, cognitive evaluation, polypharmacy review, advance directives, and caregiver information. For geriatricians and senior care practices.
Hand & Upper Extremity Surgery Intake Form
Hand and upper extremity surgery intake covering hand and wrist symptoms, functional limitations, injury mechanism, nerve and tendon assessment, prior hand surgeries, and occupational demands. For hand surgeons and upper extremity specialists.
Hearing Aid Evaluation Form
Hearing aid evaluation and audiology intake form for audiologists, ENT practices, and hearing clinics. Captures hearing history, noise exposure, communication difficulties, current hearing aids, insurance verification, and appointment scheduling for hearing assessments.
Home Health Intake Form
Home health intake covering homebound status, functional assessment, fall risk, medication management, caregiver support, and home safety evaluation. For home health agencies, visiting nurse services, and home-based primary care programs.
Hormone Replacement Therapy Intake Form
A hormone replacement therapy intake form for HRT clinics and endocrine practices, capturing symptom assessment, hormone treatment history, current medications, lab results, treatment goals, and informed consent.
Hospice & Palliative Care Intake Form
Hospice and palliative care intake covering terminal diagnosis, symptom burden assessment, advance directives, caregiver information, spiritual and psychosocial needs, and goals of care. For hospice agencies, palliative care programs, and end-of-life care teams.
Infectious Disease Intake Form
Infectious disease-specific intake covering infection history, travel and exposure assessment, immunization records, antimicrobial therapy history, and immune status evaluation. For ID consultations, HIV clinics, and tropical medicine practices.
Insurance Verification Form
Collect insurance card photos (front and back), policy details, group number, and subscriber information. Enables pre-visit insurance verification to reduce claim denials.
