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Hospital Intake Sheet PDF Details

Hospitals are a necessary part of healthcare, and patients rely on them for a variety of treatments and services. The hospital intake sheet form is an important document that helps to keep track of patients when they arrive at the hospital. This form includes information such as the patient's name, medical history, and insurance details. It's important for hospitals to have accurate information about patients so that they can provide the best possible care. The hospital intake sheet form is also used to bill patients' insurers for services rendered.

The listing has got information about the hospital intake sheet. You can learn its length, the typical time to complete the form, the blanks you'll need to fill in, and so forth.

Question	Answer
Form Name	Hospital Intake Sheet
Form Length	6 pages
Fillable?	Yes
Fillable fields	450
Avg. time to fill out	30 min 31 sec
Other names	sample hospital intake form, admission intake form, get intake sheet pdf, information on hospital sign in form

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Form Preview Example

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

Email

Employer

Phone

H:

M:

W:

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

	Have you ever had a blood transfusion?		Yes		No

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

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

No

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Yes

No

Have you considered stopping?

Yes

No

Have you ever experienced blackouts?

Yes

No

Are you prone to “binge” drinking?

Yes

No

Do you drive after drinking?

Yes

No

Tobacco

Do you use tobacco?

Yes

No

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 examples of hospital patient intake admission 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 examples of hospital patient intake admission 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.

completing general intake sheet step 1

Type in the requested data in the section .

step 2 to filling out general intake sheet

Write all information you may need within the box Surgeries, Year, Reason, Other, hospitalizations Year, Reason, Hospital, and Hospital.

stage 3 to entering details in general intake sheet

You should write down the rights and responsibilities of the sides within the Have, you, ever, had, a, blood, transfusion Yes, Name, the, Drug Strength, Frequency, Taken Allergies, Name, the, Drug and Reaction, You, Had space.

Haveyoueverhadabloodtransfusion, Yes, NametheDrug, Strength, FrequencyTaken, Allergies, NametheDrug, and ReactionYouHad in general intake sheet

Finalize by reviewing the next areas and writing the required information: Any, Other, Allergies

general intake sheet AnyOtherAllergies 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.

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