801-797-5901

New Patient Intake Survey.

Patient Survey

First Name *

Last Name *

Phone *

Email *

MEDICAL HISTORY

What questions, concerns or problems would you like to discuss

List or Update Your Medical & Surgical History

Have You Had Any Illnesses, Injuries or Hospitalizations

MEDICAL HISTORY (cont)

List Or Update Any Current Prescriptions Or Medications You Are Taking

List or Update Any Allergies, Including Your Reaction

List Any Vitamins, Herbals, Supplements, Or Over The Counter Medications, Including The Name Dose, # Of Tablets, And How Often They Are Taken

FAMILY HISTORY

Is Your Father... Alive or Deceased?

Alive

Deceased

FAMILY HISTORY (cont)

Fathers - Age

FAMILY HISTORY (cont)

Fathers - Deceased Age

Fathers - Cause of Death

FAMILY HISTORY (cont)

Is Your Mother... Alive or Deceased?

Alive

Deceased

FAMILY HISTORY (cont)

Mothers - Age

FAMILY HISTORY (cont)

Mothers - Cause Of Death

Mothers - Deceased Age

FAMILY HISTORY (cont)

Number of Siblings - Living

Number of Siblings - Deceased

Number of Siblings - Cause of Death

FAMILY HISTORY (cont)

List Any Additional illnesses In Your Family.

SOCIAL HISTORY

Are You A Tobacco User?

No

Yes

If Your a Smoker For How Many Years?

If You Quit Smoking, What Was The Date?

SOCIAL HISTORY (cont)

How Often Do You Drink Alcohol?

List Any Illegal Substances You Use

SOCIAL HISTORY (cont)

Do You Exercise?

Yes

No

SOCIAL HISTORY (cont)

Exercise Frequency - Min Per Day

Exercise Frequency - Days A Week

SOCIAL HISTORY (cont)

Do You Use Your Seatbelt?

Yes

No

SOCIAL HISTORY (cont)

What is Your Marital Status?

Married

Single

SOCIAL HISTORY (cont)

If Married - Years

If Married - Age Of Spouse

If Married - Spouse Health

SOCIAL HISTORY (cont)

Do You Have Kids?

Yes

No

SOCIAL HISTORY (cont)

What is Your Occupation?

Do You Have a Religious Preference?

List Any Special Interests or Hobbies

MEDICAL QUESTIONS

Do You Have Any Advanced Directives?

Do You Have a Durable Power of Attorney for Medical Care?

Yes

No

FEMALES, ONLY

Females, Only - Age of First Menstrual Period

Females, Only - Age of Last Menstrual Period

Females, Only - Date of Last Menstrual Period

REVIEW OF SYSTEMS

Review Of Systems - Constitutional

Review Of Systems - Genitourinary

Review Of Systems - Eyes

Review Of Systems - Musculoskeletal

REVIEW OF SYSTEMS (cont)

Review Of Systems - Ear / Nose / Throat

Review Of Systems - Integumentary (Skin)

Review Of Systems - Cardiovascular

Review Of Systems - Neurological

REVIEW OF SYSTEMS (cont.)

Review Of Systems - Psychological

Review Of Systems - Respiratory

Review Of Systems - Endocrine

Review Of Systems - Gastrointestinal

REVIEW OF SYSTEMS (cont.)

Review Of Systems - Hematologic / Lympatic

Review Of Systems - Sexual History

Review Of Systems - Allergic / Immunologic

REVIEW OF SYSTEMS (cont.)

How Long Have You Had These Symptoms?

What, if Anything, Helps to Alleviate the Symptoms?

Pain Level 0 = No Pain through 10 = Worst Pain Ever Experienced

REVIEW OF SYSTEMS (cont.)

List Any Additional Symptoms. (Ex. cough, congestion, ear ache, sore throat)

HEALTH SCREENINGS

Health Screenings - Date of Last Tetanus Shot

Health Screenings - Date of Last Flu Shot

Health Screenings - Date of Last Eye Exam

HEALTH SCREENINGS

Health Screenings - Date of Last Colonoscopy Screening

Health Screenings - Date of Last Bone Density Exam

Health Screenings - Date of Last Pap Smear

HEALTH SCREENINGS

Health Screenings - Date of Last Mammogram

Health Screenings - Date of Last Prostrate Exam

Thank you for completing the survey.

.....4698 Highland Dr. Millcreek, Utah 84117

....801-797-5901

....[email protected]

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.....4698 Highland Dr. Millcreek, Utah 84117

....801-797-5901

....[email protected]

Get In Touch

Stay up to date and follow us on social

Quick Link

New Patient Intake Survey.

.....4698 Highland Dr. Millcreek, Utah 84117

....801-797-5901

Get In Touch

Stay up to date and follow us on social

Quick Link

Copyright 2024 Regenerative Wellness | Powered by Regenerative Wellness

.....4698 Highland Dr. Millcreek, Utah 84117

....801-797-5901

Get In Touch

Stay up to date and follow us on social

Quick Link

Copyright 2024 Regenerative Wellness | Powered by Regenerative Wellness