Medical Intake Form

First Name

Middle Name

Last Name

Patient Initials and Last Name

Phone

Email

Whatsapp Number

Age

Date Of Birth: Day/Month/Year

Sex

Female

Male

Other

ID Number

Address

Website/URL

Do you have any Existing Conditions? Check Below:

Does your family, or did you family have any Medical Conditions? Check Below:

Other Conditions / Illnesses / Diseases

Allergies

Have you been admitted to hospital/clinic/facility or had surgery, or operations ever?

No

Yes

Names & Dosages of any Medications / Drugs / Supplements / Vitamins / Minerals / Edibles / Herbals / Homeopathics you have taken

Drugs / Alcohol

Drugs

Alcohol

Have you / or do you, use any type of Vape / Tobacco / Cigarettes / Drugs?

Yes

No

How Often Do you Consume Alcohol?

Are you Currently Under any Medical Treatment?

Emergency Contact: First Name

Emergency Contact: Middle Name

Emergency Contact: Last Name

Emergency Contact: Phone Number

Emergency Contact: Email Address

Appointment: What would you like to visit Dr Brom for? What are your main symptoms? What do you hope to achieve from this consultation / treatment?

I hereby consent to and authorize Dr Lauren Brom to use in person examinations and / or telemedicine in the course of my diagnosis and treatment. Sign Below:

Signature of Patient (or person authorized to sign for Patient). Sign Below:

Date:

If Authorized Signer, Relationship to Patient:

Witness: Sign Below:

Date: