New Patient Intake Form

If you prefer, you can download a PDF version of this form here.

Please complete this form before arriving for your appointment. Your data will be saved and sent securely to the MIRC staff. You will also be able to download a PDF version of the data once you have completed the form.

Male Female
Yes No


Please rate your condition on a scale of 1-10, with 1 being normal lifestyle and 10 being severe effects on lifestyle.

1 2 3 4 5 6 7 8 9 10

Yes No

MIRC Patient Intake Form for: Last Name, First Name MI
Appointment Date: July 4, 2014
Page 2 of 5

20% Complete

20% Complete
1:
1:
2:
2:
3:
3:
4:
4:
5:
5:

1:
1:
2:
2:
3:
3:
4:
4:
5:
5:
6:
6:
7:
7:
8:
8:
9:
9:
10:
10:
11:
11:
12:
12:
13:
13:
14:
14:
15:
15:
16:
16:
17:
17:
18:
18:
19:
19:
20:
20:

MIRC Patient Intake Form for: Last Name, First Name MI
Appointment Date: July 4, 2014
Page 3 of 5

40% Complete

40% Complete

Please check Yes if you have ever had any of the following conditions

Anemia
Yes No
HIV/AIDS
Yes No
Asthma
Yes No
Irregular Heartbeat
Yes No
Arthritis
Yes No
Jaundice
Yes No
Bladder Disease
Yes No
Kidney Failure
Yes No
Bleeding Tendencies
Yes No
Kidney Stones
Yes No
Bronchitis
Yes No
Measles
Yes No
Cancer
Yes No
Mental Illness
Yes No
Cataracts
Yes No
Mumps
Yes No
Chicken Pox
Yes No
Poliomyelitis
Yes No
Dementia (Memory Problems)
Yes No
Rheumatic Fever
Yes No
Diabetes
Yes No
Scarlet Fever
Yes No
Emphysema
Yes No
Sexually Transmitted Disease
Yes No
Gallbladder Disease
Yes No
Seizures
Yes No
Gastro-esophageal Reflux Disease (GERD)
Yes No
Skin Lesions/Severe Rash
 
Yes No
Glaucoma
Yes No
Sickle Cell Disease
Yes No
Hearing Loss
Yes No
Stroke
Yes No
Heart Disease/Heart Attack
Yes No
Thyroid Disease
Yes No
Hepatitis:
Yes No
Tuberculosis
Yes No
High Blood Pressure
Yes No
High Cholesterol
Yes No

1:
1:
2:
2:
3:
3:
4:
4:
5:
5:

MIRC Patient Intake Form for: Last Name, First Name MI
Appointment Date: July 4, 2014
Page 4 of 5

60% Complete

60% Complete
Grammar School High School GED College After College Education Doctorate
Tobacco
(Cigarettes, Snuff, Chewing, Pipes, Cigars)

Yes No

Yes No

Smokers


 

Yes No

Yes No

Alcohol

 

Yes No

Yes No

Illicit Drugs

 

Yes No

Yes No

Exercise

 

Yes No

Yes No


Please answer questions regarding family medical history

Yes No

Yes No

Alzheimer's Disease
Yes No
Epilepsy
Yes No
Asthma
Yes No
Heart Problems
Yes No
Arthritis
Yes No
Hearing Loss
Yes No
Cancer
Yes No
Kidney Disease
Yes No
Cataracts
Yes No
Thyroid Disease
Yes No
Diabetes
Yes No
High Blood Pressure
Yes No

MIRC Patient Intake Form for: Last Name, First Name MI
Appointment Date: July 4, 2014
Page 5 of 5

80% Complete

80% Complete

Please note if you have experienced any of these symptoms in the past 6 months.

Click on the symptom to note that you have experienced it. It will change color to indicate that you've selected it. Click it again to de-select it if necessary.

General Easily Fatigued Fatigued Only After Exercise Fatigued Upon Waking Excessive Weight Gain Excessive Weight Loss Night Sweats Fever
Blood Anemia (Low Blood Count) Bleeding Disorders Taking Coumadin Easy Clotting Blood Clot DVT  
Skin Bleeding Easily Bruising Sores Itching Fever Varicose Veins Non-healing Leg/Foot Wounds
Glands Enlargment Pain Drainage Lymphoma      
Eyes Glasses Cataracts Trauma Infection Temporary Blindness Visual Loss Glaucoma
Ear Infection Loss of Hearing Pain Ringing in the Ears Ruptured Ear Drum    
Nose Sinus Infection Nose Bleeds Runny Nose        
Mouth/Throat Difficulty Chewing Excessive Tongue Movement Pain Dentures Frequent Sore Throat Hoarseness Pain or Difficulty Swallowing
Neck Limitation of Movement Pain Stiffness Trauma Weakness Swelling  
Respiratory Asthma Coughing Lung Infections Coughing Up Mucus Coughing Up Blood Shortness of Breath at Rest Shortness of Breath after Exertion
Heart/CV Irregular Heart Beat Chest Pain Cold Hands and/or Feet Pain in Legs After Walking Palpitations Shortness of Breath Swelling of Hands and/or Feet
GI Nauesa Indigestion Vomiting Abdomen in Pain Vomiting Blood Jaundice (Yellow Skin) Blood in Stool
Genitourinary Change of Color in Urine Decreased Urination Painful Urination Frequent Urination at Night Increased Urination Change in Menstrual Cycle Erectile Dysfunction/Impotence
Skeletal Generalized Weakness of Muscles Muscle Paralysis Decrease in Muscle Size Decrease in Muscle Strength Involuntary Movement Arthritis Joint Pain
Neurological Dizziness Falls/Balance Difficulty Slurred Speech Severe Headaches Seizure Burning Pain / Numbness / Tingling Low Back Pain
Psychiatric Memory Loss Difficulty Focusing Depression Mood Swings Sleep Disturbance Black Outs Light Headedness

The following questionnaire is intended to help us better evaluate and treat your medical problems. We appreciate you filling it out in its entirety. Should you have any questions about what information to include, don't hesitate to ask the office staff.

MIRC Patient Intake Form for: Last Name, First Name MI
Appointment Date: July 4, 2014
Completed

100% Complete

100% Complete
Form Completed
Saving

Please Wait

We're currently saving your questionnaire. Please wait while this process completes.

Error

Oops

Something went wrong while saving your questionnaire. You can still print your responses, however, by clicking here or by hitting the Print button in your browser. (Your answers will still print, even though you cannot see them currently.)

Completed

Thank you!

Your questionnaire has been saved securely and sent to the Memphis Interventional Radiology Clinic location you've selected.

If you like, you can download a completed PDF version of your questionnaire by clicking this link. This link will only work on this computer and will expire in one hour.