ELECTRONIC HEALTH RECORDS INTAKE FORM

Name*

Email*

Phone*

Preferred method of communication for patient reminders

Email
Phone
Mail

DOB

Gender

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Female

Preferred Language

Smoking Status

Every Day Smoker
Occasional Smoker
Former Smoker
Never Smoked

Race

American Indian or Alaska Native
Asian
Black or African American
White (Caucasian)
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Other
I Decline to Answer

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
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Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name - Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies?

Medication Name - Reaction - Onset Date - Additional Comments

I choose to decline receipt of my clinical summary after every visit

Yes
No

LOCATION

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6405 Telegraph RD, Bloomfield Hills, MI 48301, US

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CONTACT US

Please do not submit any Protected Health Information (PHI).

Name

Phone

Notes to the Doctor

PARAGON CHIROPRACTIC

AND WELLNESS CENTER

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