Healthcare Form Templates

Comprehensive intake form for interventional radiology practices performing minimally invasive image-guided procedures. Captures procedure history, contrast allergies, bleeding risks, and anticoagulation medications critical for safe IR interventions.

IV hydration therapy intake form for mobile IV services, IV vitamin drip bars, and infusion wellness clinics. Covers health screening, allergies, current medications, hydration package selection, payment processing, and informed consent.

Ketamine therapy intake form for clinics offering ketamine infusions and psychedelic-assisted therapy. Covers mental health history, contraindications screening, current medications, treatment goals, emergency contact, and informed consent for ketamine treatment.

Lactation consultation intake form for IBCLCs, breastfeeding consultants, and lactation support practices. Captures mother and baby information, birth details, feeding history, current concerns, medications, insurance verification, and appointment scheduling.

Male fertility and andrology intake covering reproductive history, semen analysis results, hormonal assessment, sexual health, lifestyle factors, and prior fertility treatments. For reproductive urology, andrology, and fertility clinics.

Massage therapy intake covering areas of tension and pain, pressure preferences, contraindication screening, treatment goals, and health history. For licensed massage therapists and bodywork practices.

Med spa intake covering aesthetic goals, skin type assessment, treatment history (injectables, laser, chemical peels), contraindication screening, and photo consent. For medical spas, aesthetics practices, and cosmetic dermatology clinics.

Nephrology-specific intake covering kidney function history, CKD staging, dialysis access, fluid and diet management, and renal medication reconciliation. For nephrologists, dialysis centers, and kidney transplant programs.

Neurology-specific intake with headache assessment, seizure history, cognitive screening, neurological symptom checklist, and prior imaging review. For neurologists, headache centers, and epilepsy clinics.

Obstetrics and gynecology intake with menstrual history, pregnancy history, contraceptive use, gynecological symptoms, and reproductive health screening. For OB/GYN and women's health practices.

OT-specific intake covering functional limitations, ADL assessment, hand and upper extremity evaluation, workplace ergonomics, and treatment goals. For occupational therapists, hand therapy, and rehabilitation clinics.

Oncology-specific intake covering cancer diagnosis details, treatment history, chemotherapy regimens, symptom management, and psychosocial screening. For medical oncology, radiation oncology, and cancer centers.

Eye care intake form with vision history, current symptoms, eye surgery history, contact lens/glasses prescription, and family eye disease history. For ophthalmology and optometry practices.

Orthopedic intake covering musculoskeletal complaints, injury mechanism, imaging history, joint function assessment, and surgical history. For orthopedic surgeons and sports medicine practices.

Pain management intake with pain mapping, numeric rating scales, functional assessment, opioid risk screening, and interventional procedure history. For pain medicine, spine, and chronic pain clinics.

Pediatric dentistry intake covering child's dental history, oral development milestones, dental anxiety assessment, dietary habits, fluoride exposure, and parent/guardian consent. For pediatric dental practices and children's oral health programs.

Pelvic floor therapy intake form for pelvic floor physical therapists and pelvic rehabilitation specialists. Covers bladder and bowel symptoms, obstetric and surgical history, pain assessment, current medications, insurance verification, and treatment consent.

PT-specific intake with injury mechanism, pain assessment (VAS scale), functional limitations, range of motion goals, and treatment expectations. For physical therapy, sports medicine, and rehabilitation clinics.

Plastic surgery intake covering cosmetic goals, procedure history, medical clearance, body dysmorphia screening, and photo consent. For plastic surgeons, cosmetic surgery centers, and reconstructive practices.

Podiatry-specific intake covering foot and ankle symptoms, diabetic foot screening, gait assessment, footwear history, and prior podiatric procedures. For podiatrists, foot and ankle surgeons, and diabetic foot care clinics.

Psychiatry-specific intake covering psychiatric history, medication trials, substance use assessment, safety screening, and psychosocial evaluation. For psychiatrists, psychiatric nurse practitioners, and medication management clinics.

Pulmonology-specific intake covering respiratory symptoms, asthma and COPD assessment, smoking history, pulmonary function testing, and oxygen therapy documentation. For pulmonologists and respiratory care clinics.

Rheumatology-specific intake covering joint symptoms, autoimmune screening, morning stiffness assessment, prior biologic therapy, and functional limitations. For rheumatologists and autoimmune disease clinics.

Sleep medicine intake covering sleep habits, insomnia assessment, sleep apnea screening (STOP-BANG), Epworth Sleepiness Scale, CPAP history, and circadian rhythm evaluation. For sleep centers and pulmonary sleep clinics.

Sober living and recovery housing intake form for halfway houses, sober living homes, and transitional housing programs. Captures personal history, substance use timeline, treatment history, current medications, emergency contact, and house rules consent agreement.

Speech therapy intake covering communication concerns, speech and language development, swallowing assessment, voice disorders, and treatment history. For speech-language pathologists and communication disorder clinics.

Sports medicine intake with athletic history, sport-specific injury assessment, training regimen, concussion history, and return-to-play goals. For sports medicine and athletic training facilities.

Travel medicine-specific intake covering itinerary details, destination risk assessment, immunization history, malaria prophylaxis planning, and chronic disease travel considerations. For travel clinics and international health practices.

Streamlined intake for urgent care and walk-in clinics. Captures chief complaint, symptom timeline, vitals triage, allergies, and current medications in a fast-paced single-page format.

Urology-specific intake covering urinary symptoms, prostate health assessment, kidney stone history, sexual health screening, and prior urologic procedures. For urologists and men's health clinics.