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.

Last Name

First Name

Middle Initial

Date of Birth

Age

Sex

Male Female

Social Security Number

Marital Status

Date of Your Appointment

Email Address

Would you like to be contacted by email?

Yes No

Home Address

City

State

Zip Code

Preferred Phone Number to be contacted

Preferred Number

In Case of Emergency, Contact Name

Emergency Contact Phone

Relationship

Primary Care Physician

Primary Phone Number

Date of Last Visit

Preferred Pharmacy

Pharmacy Phone

Who should we thank for your referral?

Referring Phone Number (if applicable)

Primary Insurance Company

Employer of Insured

ID or Policy Number

Policy Holder or Insured Name/DOB

Group Number

Pre-Certification Phone Number

Secondary Insurance Company

Employer of Insured

ID or Policy Number

Policy Holder or Insured Name/DOB

Group Number

Pre-Certification Phone Number

Symptoms or Reason for Visit

Previous Treatments for Problem (Meds or Surgery, Etc.)

When did you first notice the problem?

How often do you have these problems?

Family History of Similar Problems

Yes No

What is the medical problem you need addressed today?

Does anything make your problem worse or better?

Have you been evaluated for this problem before/what was the diagnosis given?

Please list allergies (medications or foods): (List one per line.)

Type of Reaction (rash, difficulty breathing, etc)

Please list all medications (including over-the-counter, vitamins and herbals): (List one per line.)

Strength and frequency

Please list all implants (penile, breast, pacer, etc.):

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

Other medical conditions not listed above:

High Cholesterol

Yes No

Please list major hospitalizations and surgeries: (List one per line.)

Year

Employer

How long have you worked there?

Please list all exposures to toxic chemicals or gases:

Travel History (Please list travel to foreign countries over the past 3 years)

Tobacco
(Cigarettes, Snuff, Chewing, Pipes, Cigars)

Recent

Yes No

Past

Yes No

Amount

Smokers

Are you trying to quit smoking?

Yes No

Would you like treatment to stop smoking?

Yes No

Alcohol

Recent

Yes No

Past

Yes No

Amount

Illicit Drugs

Recent

Yes No

Past

Yes No

Type of Drugs

Exercise

Recent

Yes No

Past

Yes No

Amount

Please answer questions regarding family medical history

Mother's age (or age at death) and medical problems (if not listed below)

Alive?

Yes No

Father's age (or age at death) and medical problems (if not listed below)

Alive?

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

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.

Please choose which location your appointment is at:

Please type your name to indicate you have signed this questionnaire.

Date

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

100% Complete

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

New Patient Intake Form

20% Complete

40% Complete

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

60% Complete

Please answer questions regarding family medical history

80% Complete

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

100% Complete

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