Get Patient Intake Form - Northwestern Health Sciences University - Nwhealth

Filling out the patient intake form is a crucial step in receiving health care services. This guide will provide you with a detailed, step-by-step approach to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the online patient intake form.

1. Press the ‘Get Form’ button to access the patient intake form and open it in your preferred editor.
2. Begin by entering your personal information, including your full name, date, account number, primary healthcare provider, address, and phone number. Ensure all details are accurate.
3. Next, address the questions related to your chief complaints by checking all applicable boxes to indicate your current health issues.
4. On the provided body form, mark with an ‘X’ the locations of any pain or discomfort, and use the symbols to describe the pain experienced over the past week.
5. Fill out the health history section by listing any current or past health issues, specifying any significant family health histories, allergies, surgeries, and any traumas or injuries.
6. List your current medications, including the dosage and purpose, along with the name of the prescriber.
7. Indicate your preventive health screenings and their dates for specific health evaluations.
8. Respond to lifestyle questions regarding alcohol, caffeine, tobacco usage, and physical activity frequency over the past month.
9. Reflect on your overall sense of well-being over the previous month on the provided scale.
10. Indicate your marital status, education level, and your race according to the federal definitions.
11. Read and sign the acupuncture informed consent form, acknowledging your understanding of the treatment and potential side effects.
12. Review and sign the consent for use and disclosure of your protected health information, ensuring you understand your rights regarding your health information.
13. Once all sections are completed, save the changes, and choose to download, print, or share the completed form as needed.

Complete your patient intake form online today and ensure the best care for your health.