Hospital Intake Sheet – Fill Out and Use This PDF

Hospital Intake Sheet – Fill Out and Use This PDF

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Hospital Intake Sheet – Fill Out and Use This PDF

The Hospital Intake Sheet form, an essential document in healthcare, is designed to gather comprehensive information about a patient's medical history, current health concerns, and personal health practices. This form, filled out upon admission or during the first visit, is a vital tool used by healthcare providers to tailor patient care precisely. For a smooth and efficient intake process, ensure you have all the necessary information ready and click the button below to fill out the form.

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Hospital Intake Sheet PDF Details

When stepping into a hospital for care, patients are often greeted with a Hospital Intake Sheet form, a crucial document that begins the patient-care provider relationship. This comprehensive form is designed to collect detailed information about the patient, including personal details, health history, and lifestyle habits, ensuring that healthcare providers have a full picture of the person they are treating. From basic information like name, address, and occupation to more sensitive details regarding health conditions, surgeries, and medications, every question serves a vital purpose. It delves into family health history, personal safety habits, dietary preferences, and substance use, reflecting an understanding that health is affected by a wide range of factors. Moreover, the form includes sections tailored to specific groups, such as questions relevant only to women or men, highlighting the personalized approach to patient care. By providing a space for patients to list their primary health concerns and goals, it ensures that their initial interactions with healthcare professionals are focused and productive. The confidentiality of the information gathered is a cornerstone of the process, emphasizing the trust and privacy essential to the patient-provider relationship. This form, while seemingly simple, initiates a critical dialogue that shapes the patient’s care trajectory.

Question	Answer
Form Name	Hospital Intake Sheet
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	hospital intake forms, sample hospital intake form, get intake sheet pdf, hospital admission face sheet fillable

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PATIENT INTAKE QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential

and will become part of your medical record.

Name (Last, First, M.I.):

Today’s Date

Address (Street.):

Date of Birth

(City, State, Zip.):

Occupation

Employer

Phone

Marital status:

Single

Partnered

Married

Separated

Divorced

Widowed

Children (Names, Ages)

Previous or referring doctor:

Date of last physical exam:

How did you hear about me?

CHIEF COMPLAINT

What is the primary health concern or goal that brings you to the clinic?

Brief History of Chief Complaint (when it started, what makes it better/worse, severity, etc)

List other health issues you hope to address

PERSONAL HEALTH HISTORY

List any other medical problems that other doctors have diagnosed

Surgeries

Year	Reason

Hospital

Other hospitalizations

Year

Reason

Hospital

Name the Drug

Strength

Frequency Taken

Allergies

Name the Drug	Reaction You Had



Any Other Allergies

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise Describe exercise activities: the frequency, intensity, time and type of activity. For example (twice weekly beginner 1 hour yoga classes)

Activities Describe your interests, hobbies, spiritual practices, things you do to relax

Diet	Are you dieting?	Yes	No
	If yes, are you on a physician prescribed medical diet?	Yes	No

#of meals you eat in an average day? What Have you eaten in the last 24 hours?

If the above dietary recall is atypical for you, describe a typical day here.

List your favorite healthy foods

Caffeine

None

Coffee

Tea

Cola

Number of cups/cans per day?

Alcohol

Do you drink alcohol?

Yes

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Yes

Have you considered stopping?

Yes

Have you ever experienced blackouts?

Yes

Are you prone to “binge” drinking?

Yes

Do you drive after drinking?

Yes

Tobacco

Do you use tobacco?

Yes

Cigarettes – pks./day:

Chew - #/day:

Pipe - #/day:

Cigars - #/day:

# of years:

Or year quit:

Drugs	Do you currently use recreational or street drugs?	Yes	No

	Have you ever given yourself street drugs with a needle?	Yes		No
Sex	Are you sexually active?	Yes	No
	If yes, are you trying for a pregnancy?	Yes		No
	If not trying for a pregnancy list contraceptive or barrier method used:

	Any discomfort with intercourse?	Yes		No
Personal	Do you live alone	Yes		No
Safety
Safety	Do you have traction stickers or bathtub mat?	Yes		No
	Do you have traction stickers or bathtub mat?	Yes		No

	Do you have a fire extinguisher?	Yes		No
	Do you have frequent falls?	Yes	No

	Do you have vision or hearing loss?	Yes		No
	Do you have an Advance Directive or Living Will?	Yes	No

	Do you wear a seatbelt?	Yes		No

FAMILY HEALTH HISTORY

FOR DECEASED RELATIVES MARK A LETTER “D” AND THEIR AGE AT DEATH, SPECIFY CAUSE OF DEATH IF KNOWN

	AGE	SIGNIFICANT HEALTH PROBLEMS		AGE	SIGNIFICANT HEALTH PROBLEMS

Father			Children	M
Father			Children	F
				F
Mother				M
Mother				F
				F
Sibling(s)	M			M
Sibling(s)	F			F
	F			F
	M			M
	F			F
	M
	F		Grandmother
	M		Maternal
	F
	M
	F		Grandfather
	M		Maternal
	F
	M
	F		Grandmother
	M		Paternal
	F
	M
	F		Grandfather
	M		Paternal
	F

WOMEN ONLY

Age at onset of menstruation:

Date of last menstruation:

Period every how many days?

Heavy periods, irregularity, spotting, pain, or discharge?		Yes	No
Number of pregnancies:	Number of live births:

Are you pregnant or breastfeeding?		Yes	No
Have you had a D&C, hysterectomy, or Cesarean?		Yes	No

Any urinary tract, bladder, or kidney infections within the last year?		Yes	No
Any blood in your urine?		Yes	No

Any problems with control of urination?		Yes	No
Any hot flashes or sweating at night?		Yes	No

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?		Yes	No
Experienced any recent breast tenderness, lumps, or nipple discharge?		Yes	No

Date of last pap?

MEN ONLY

Do you usually get up to urinate during the night?

If yes, # of times:

Do you feel pain or burning with urination?

Any blood in your urine?

Do you feel burning discharge from penis?

Has the force of your urination decreased?

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Do you have any problems emptying your bladder completely?

Any difficulty with erection or ejaculation?

Any testicle pain or swelling?

	Yes		No
	Yes		No
	Yes		No

	Yes		No
	Yes		No

	Yes		No
	Yes		No

	Yes		No
	Yes		No

	Yes		No

OTHER PROBLEMS

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain in the space below.

Skin	Chest/Heart	Recent changes in:
Head/Neck	Back	Weight

Ears	Intestinal	Energy level
Nose	Bladder	Ability to sleep

Throat	Bowel	Other pain/discomfort:
Lungs	Circulation	Other odd symptom

Use this space to elaborate on the above chart or for anything else you would like to add not addressed in this form.

How to Edit Hospital Intake Sheet Online for Free

The PDF editor makes it simple to create the file h intake forms lab based 5 4 2020 pdf document. You should be able to build the form immediately by using these simple steps.

Step 1: Click the button "Get Form Here".

Step 2: Once you have entered the file h intake forms lab based 5 4 2020 pdf editing page you may see all of the actions you may conduct relating to your document within the upper menu.

For every single area, fill in the content requested by the system.

Type in the requested data in the section Brief History of Chief Complaint, and List other health issues you hope.

step 2 to filling out hospital intake form

Write all information you may need within the box List any other medical problems, Surgeries, Year, Reason, Other hospitalizations, Year, Reason, Hospital, Hospital, Have you ever had a blood, and Yes.

stage 3 to entering details in hospital intake form

You should write down the rights and responsibilities of the sides within the Name the Drug, Strength, Frequency Taken, Allergies, Name the Drug, Reaction You Had, and Any Other Allergies space.

Name the Drug, Strength, Frequency Taken, Allergies, Name the Drug, Reaction You Had, and Any Other Allergies in hospital intake form

Finalize by reviewing the next areas and writing the required information: Exercise, Describe exercise activities the, Activities, Describe your interests hobbies, Diet, Are you dieting, If yes are you on a physician, of meals you eat in an average day, What Have you eaten in the last, Yes, and Yes.

hospital intake form Exercise, Describe exercise activities the, Activities, Describe your interests hobbies, Diet, Are you dieting, If yes are you on a physician, of meals you eat in an average day, What Have you eaten in the last, Yes, and Yes blanks to fill

Step 3: Once you click on the Done button, your completed file is easily exportable to every of your gadgets. Or, it is possible to deliver it using mail.

Step 4: Be certain to remain away from potential challenges by creating as much as 2 duplicates of your document.

Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers