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.

QuestionAnswer
Form NameHospital Intake Sheet
Form Length6 pages
Fillable?Yes
Fillable fields450
Avg. time to fill out30 min 31 sec
Other namessample hospital intake form, admission intake form, get intake sheet pdf, information on hospital sign in form

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

 

 

 

 

 

 

 

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

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

Mother

 

 

 

 

M

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

Sibling(s)

M

 

 

 

M

 

 

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

 

 

 

 

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, Otherhospitalizations, 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 Haveyoueverhadabloodtransfusion, Yes, NametheDrug, Strength, FrequencyTaken, Allergies, NametheDrug, and ReactionYouHad 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: AnyOtherAllergies.

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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