Patient Intake Form Template
New-patient intake form for clinics — demographics, insurance, medical history snapshot, consents.
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PACIFIC NW FAMILY MEDICINE 925 NW 19th Ave, Portland, OR 97209 +1 503 555 0410 ═══════════════════════════════════════════════════════════════════════ NEW-PATIENT INTAKE FORM Date of intake: May 4, 2026 ═══════════════════════════════════════════════════════════════════════ DEMOGRAPHICS Name: Jordan Alex Taylor Date of birth: June 12, 1985 Sex / gender: Female Preferred pronouns: she/her Preferred language: English Address: 482 Elm Street, Apt 3B, Portland, OR 97214 Phone: +1 503 555 0118 Email: jordan.taylor@example.com Emergency contact: Sam Taylor — +1 503 555 0142 — sister ═══════════════════════════════════════════════════════════════════════ INSURANCE Primary: BlueCross BlueShield Oregon — policy 88312-Q — group GRP-OR-44218 Secondary: none ═══════════════════════════════════════════════════════════════════════ REASON FOR VISIT New-patient establish-care visit. Annual physical. Recent migraine-frequency increase to discuss. ═══════════════════════════════════════════════════════════════════════ CURRENT MEDICATIONS Sumatriptan 50 mg — as needed for migraine, max 2x/week. Multivitamin daily. Albuterol inhaler — as needed for exercise-induced wheezing. ═══════════════════════════════════════════════════════════════════════ ALLERGIES Penicillin — rash + hives at age 9. Peanuts — anaphylaxis (EpiPen carried). No latex allergy. ═══════════════════════════════════════════════════════════════════════ PAST MEDICAL / SURGICAL HISTORY Mild exercise-induced asthma — diagnosed age 14, well controlled. Migraine — diagnosed age 22, episodic, no aura. Appendectomy 2014. No other surgical history. No hospitalisations. ═══════════════════════════════════════════════════════════════════════ FAMILY MEDICAL HISTORY Mother: type 2 diabetes (diagnosed age 58); hypertension. Father: coronary artery disease (CABG age 64); deceased age 71. Maternal grandmother: breast cancer (deceased age 73). No known family history of clotting disorders, autoimmune disease, or major mental illness. ═══════════════════════════════════════════════════════════════════════ SOCIAL HISTORY Alcohol: 2-4 drinks/week, social. Tobacco: never. Recreational drugs: occasional cannabis (legal in OR), no other. Exercise: 3-4x/week, mix of running and yoga. Diet: omnivorous, mostly home-cooked. ═══════════════════════════════════════════════════════════════════════ IMMUNIZATIONS Status: Yes — records will be uploaded to portal ═══════════════════════════════════════════════════════════════════════ ACKNOWLEDGEMENTS By signing below, I confirm: • The information provided above is accurate to the best of my knowledge. • I have received and reviewed the practice's Notice of Privacy Practices (HIPAA). • I authorise the practice to bill my insurance for services rendered. • I am financially responsible for any portion of services not paid by insurance, consistent with my plan benefits. _______________________________ Date: ____________________ Jordan Alex Taylor (Patient or guardian)
About this template
A patient intake form is the first formal document a clinic collects from a new patient. It serves four jobs simultaneously: build the medical record, verify insurance, document consent to treatment and payment responsibility, and satisfy HIPAA Notice-of-Privacy-Practices delivery (which the patient must acknowledge having received). Most modern practices have moved intake to digital portals (Athenahealth, Epic MyChart, NextGen, Practice Fusion), pre-filled before the visit and reviewed at check-in; paper intakes still exist for walk-in clinics, urgent care, and specialty offices. The most clinically-actionable sections are allergies (errors here cause the largest medication-error categories), current medications (drug interactions), and past surgical/medical history (anaesthesia risk). The most billing-actionable sections are insurance information and the financial-responsibility acknowledgement. Many intakes also collect social history (alcohol, tobacco, drugs, sexual history) — these are clinically important but should be collected with care; many patients under-report sensitive items on paper forms. Best practice is to make these optional on the intake and revisit during the in-person interview, where a trained clinician can ask non-judgmentally. Forms should be reviewed and updated at least annually for established patients; major life changes (new diagnosis, new medication, new insurance) trigger immediate updates.
When to use it
- New patient establishing care.
- Annual update of an established patient's record.
- After a major change in insurance, medications, or medical history.
- Specialist consultation requiring a fresh intake.
- Urgent care or walk-in clinic visit.
What to include
- Demographics and emergency contact.
- Primary and secondary insurance.
- Current medications, allergies, past medical history.
- Family history and social history.
- Reason for visit and presenting complaint.
- HIPAA NPP acknowledgement and financial-responsibility consent.