Medical Patient Intake Notes

Personal Information Full Name: John Doe Date of Birth (DOB): 15 March 1980 Sex/Gender: Male Address: 123 Elm Street, Melbourne, VIC 3000 Phone: 0412 345 678 Email: johndoe@example.com Parent/Guardian (if minor): N/A Relationship: N/A Emergency Contact: Jane Doe Phone: 0412 987 654 Medical History Past Illnesses/Chronic Conditions: Hypertension (Lisinopril 10mg daily), Type 2 Diabetes (Metformin 500mg twice daily) Surgeries & Hospitalizations: Appendectomy (2010) Allergies: Penicillin Previous Treatments: Physical therapy for back pain Vaccinations: Influenza (2023), COVID-19 (2023) Lifestyle and Social History Smoking: Non-smoker Alcohol Use: Social drinker Recreational Drug Use: None Exercise: Regular, 3 times a week Diet: Balanced diet Occupation: Accountant Current Health Concerns Chief Complaint: Persistent headache Duration: 2 weeks Associated Symptoms: Nausea, dizziness Relevant Family History: Father with history of migraines Medications & Supplements Current Medications: - Lisinopril 10mg daily - Metformin 500mg twice daily Supplements: Vitamin D 1000 IU daily Pharmacy: Main Street Pharmacy Primary Care & Referring Provider Information Primary Care Provider: Dr. Sarah Smith Phone: 03 1234 5678 City: Melbourne Referring Provider: N/A Insurance and Billing Information Primary Insurance Provider: HealthFirst Plan Name: Comprehensive Plan Policy ID: 123456789 Group Number: 98765 Policy Holder: John Doe DOB: 15 March 1980 Consent & Authorization "I consent to medical treatment and acknowledge financial responsibility." Date: 1 November 2024 Kieran's Practice 1 Main Street Melbourne 3121