Intake Form Reader

Front desk · Form NP-1

New Patient Intake Form

Example data

Filled out by (if not the patient)

Date

Name

Date of birth

Address

Phone

Insurance

Member ID

Emergency contact (name, relationship, phone)

Reason for visit

Current medications (incl. OTC, vitamins, eye drops, inhalers)

Allergies

None

Past conditions (check all that apply)

Other

Past surgeries (procedure and year)

Family history (parents, siblings, children)

Social history

Tobacco Never Former quit Current

Alcohol None Occasional Daily

Recreational drugs No Yes

Signature

Signed by

Relationship (if not the patient)

Illustrative clinic form, not medical advice. AI-read values can be wrong — confirm with the patient.