Patient Intake

Do you have any allergies? Select an option No known allergies Medication allergies Food allergies Environmental allergies Multiple allergies

If yes, please list your allergies

Include the allergy and your reaction

Do you have any chronic conditions? Select an option No chronic conditions Diabetes High Blood Pressure Heart Disease Asthma Other

Are you taking any medications? Select an option No medications Prescription only Over-the-counter only Both prescription and OTC

List your current medications

Include name, dosage, and frequency