Patient intake form

Please take the time to complete the following information for our records. The information shared will be kept confidential and never shared with outside parties. If anything is unclear, please do not hesitate to contact us.

Patient intake form

Title

First Name

Surname

Date of birth

ID Number

Cellphone Number

Address

Gender

Male

Female

Other

Non-disclosed

Religion / Cultural group (for medication purposes)

Home language

How did you hear about us?

Relationship

Title

First Name

Surname

Date of birth

ID Number

Cellphone Number

Is the patient, completed in Step 1, responsible for the account?

Yes

Relationship

Title

First Name

Surname

Date of birth

ID Number

Medical Aid

Medical aid number

Main Member

Main member ID

Address

Cellphone Number

Previous surgeries

Current medical conditions

Current health supplements

Previous medical conditions

Current medication

Allergies or intolerances

Dietary preferences

Do you consume any of the following? How much?

Caffeine

Alcohol

Tobacco

Do you exercise? What kind and how often?

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