Template library · Intake forms
Medical Intake template
Full medical intake covering demographics, insurance, health history, medications, and current symptoms.
- 22 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Contact & Demographics
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Home addressText
- Emergency contact (name & phone)Text
Insurance
- Insurance providerText
- Policy numberText
- Group numberText
Health History
- Reason for today’s visitText
- Current medicationsText
- AllergiesText
- Past surgeries or hospitalizationsText
- OtherText
- Relevant family health historyText
- Do you have any of the following? (check all that apply):
- Diabetes
- Hypertension
- Asthma
- Heart disease
- Cancer
- Thyroid disorder
Symptoms & Goals
- Symptom severityText
- How long have you had these symptoms?Choice
- What would you like to achieve from this visit?Text
- Client signatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
Spend less time on admin, more time with clients
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