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New Patient Intake & Medical History
Head2Toe Health
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* Indicates required question
Full Legal Name
*
Your answer
First Name Used (If Different):
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender Identity
*
Identifies as Male
Identifies as Female
Transgender (FTM)
Transgender (MTF)
Gender Non-Conforming
Choose not to disclose
Other:
Legal Gender (According to Government ID)
*
Male
Female
What pronouns do you use?
He/Him/His
She/Her/Hers
They/Them/Theirs
Other:
Clear selection
Sexual Orientation
Heterosexual
Homosexual
Bisexual
Prefer not to say
Other:
Clear selection
Mobile Number
*
Your answer
Email Address
*
Your answer
Home Address
*
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Insurance Policy Holder Name
*
Your answer
Policy Holder Date of Birth
*
MM
/
DD
/
YYYY
Preferred Pharmacy Name & Address
*
Your answer
Do you have any medication allergies?
*
Yes
No
If yes to allergies - please list medication and reaction:
Your answer
What brings you here today?
*
Your answer
Are you currently taking any medication, vitamins or supplements?
*
Yes
No
If so, please list any medications prescribed or OTC also include any vitamins or supplements (include dosages):
Your answer
History of Medical Conditions
Your answer
History of Surgeries or Hospitalizations?
Your answer
Do you have any family history of the following conditions?
*
Diabetes
High Blood Pressure/Hypertension
Cholesterol
Heart Disease
Autoimmune
Cancers
None
Other:
Required
If you checked any of the above, please specify the exact condition and family member
Your answer
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