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Patient Intake
A few questions before your appointment so we can make the most of the time.
Full name
*
(required)
Date of birth
*
(required)
Phone number
*
(required)
Today's problem
What's brought you in?
*
(required)
How long has it been going on?
*
(required)
Select…
Today
A few days
1 - 4 weeks
1 - 6 months
Longer
How much is it affecting you?
0
1
2
3
4
5
6
7
8
9
10
Not at all
Severely
Which of these apply?
*
(required)
Getting worse
Getting better
Comes and goes
Constant
Worse at night
Worse with activity
Worse with rest
What have you already tried?
What are you most worried this might be?
Your health
Existing medical conditions
Medication you're taking
*
(required)
Allergies
*
(required)
Any of these recently?
*
(required)
Select…
No
Unexplained weight loss
Fever or night sweats
New lumps or swelling
Something else - see notes
This visit
What would you like to get out of today?
Would you like anyone with you?
*
(required)
Select…
No
A family member or friend
An interpreter
A chaperone
Leave this field empty
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