Patient Intake Form
Last updated: May 13, 2025
A Patient Intake Form is typically used by healthcare providers to gather personal, medical, and insurance information from new or returning patients, serving as the foundation of their medical record and billing data.
Fields
| Field | Description | Example |
|---|---|---|
patient_name |
Full legal name of the patient. | Jane Doe |
date_of_birth |
Patient’s birth date. | 1980-07-12 |
address |
Mailing or residential address of the patient. | 1234 Main St, Springfield, ST 00000 |
contact_phone |
Patient's primary phone number. | (555) 123-4567 |
email_address |
Patient’s email, if provided. | [email protected] |
emergency_contact |
Name/number of a person to contact in emergencies. | John Doe, (555) 987-6543 |
insurance_provider |
Name of the patient’s primary insurance. | XYZ Health Insurance |
insurance_policy_number |
Policy or membership ID for the insurance coverage. | H123456789 |
medical_history_summary |
Brief overview of critical past medical history. | Allergies: Penicillin. Past surgeries: Appendectomy (2010). |
current_medications |
List of meds the patient is presently taking. | Metformin, Lisinopril |
date_signed |
When the patient signed the intake form. | 2023-09-01 |
patient_signature |
Signature or digital signature of the patient. | Jane Doe |
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