Nurse Template

Generic Medical Patient Intake Notes

A professional Nurse template for healthcare professionals.

About this template

The Medical Patient Intake Notes template is an essential tool for nurses and healthcare professionals to efficiently gather comprehensive patient information during initial visits. This template covers personal details, medical history, lifestyle factors, current health concerns, and insurance information, ensuring a holistic view of the patient's health status. It is particularly useful for creating a structured and thorough record that aids in patient management and continuity of care. This template is ideal for use in clinics, hospitals, and other healthcare settings, streamlining the intake process and enhancing patient care.

Preview template

Personal Information Full Name: John Doe Date of Birth (DOB): 15 March 1985 Sex/Gender: Male Address: 123 Health St, Wellness City, WC1 2AB Phone: 01234 567890 Email: johndoe@example.com Parent/Guardian (if minor): N/A Relationship: N/A Emergency Contact: Jane Doe Phone: 09876 543210 Medical History Past Illnesses/Chronic Conditions: Hypertension, Asthma Surgeries & Hospitalizations: Appendectomy in 2010 Allergies: Penicillin Previous Treatments: Beta-blockers for hypertension Vaccinations: Up-to-date Lifestyle and Social History Smoking: Non-smoker Alcohol Use: Occasional Recreational Drug Use: None Exercise: Regular, 3 times a week Diet: Balanced diet Occupation: Software Engineer Current Health Concerns Chief Complaint: Persistent cough Duration: 2 weeks Associated Symptoms: Shortness of breath, fatigue Relevant Family History: Father has a history of heart disease Medications & Supplements Current Medications: - Lisinopril - Albuterol inhaler Supplements: Vitamin D Pharmacy: Health Pharmacy, Wellness City Primary Care & Referring Provider Information Primary Care Provider: Dr. Emily Smith Phone: 01234 567891 City: Wellness City Referring Provider: Dr. Thomas Kelly Insurance and Billing Information Primary Insurance Provider: HealthFirst Plan Name: Comprehensive Care Policy ID: 123456789 Group Number: 987654321 Policy Holder: John Doe DOB: 15 March 1985 Consent & Authorization "I consent to medical treatment and acknowledge financial responsibility." Date: 1 November 2024

Personal Information Full Name: [Full Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date of Birth (DOB): [Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Sex/Gender: [Sex/Gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Address: [Address] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Phone: [Phone] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Email: [Email] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Parent/Guardian (if minor): [Parent/Guardian] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Relationship: [Relationship] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Emergency Contact: [Emergency Contact] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Phone: [Emergency Contact Phone] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medical History Past Illnesses/Chronic Conditions: [Past Illnesses/Chronic Conditions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Surgeries & Hospitalizations: [Surgeries & Hospitalizations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Allergies: [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Previous Treatments: [Previous Treatments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Vaccinations: [Vaccinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Lifestyle and Social History Smoking: [Smoking] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Alcohol Use: [Alcohol Use] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Recreational Drug Use: [Recreational Drug Use] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Exercise: [Exercise] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Diet: [Diet] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Occupation: [Occupation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Current Health Concerns Chief Complaint: [Chief Complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Duration: [Duration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Associated Symptoms: [Associated Symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Relevant Family History: [Relevant Family History] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medications & Supplements Current Medications: - [Medication 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Medication 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Supplements: [Supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Pharmacy: [Pharmacy] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Primary Care & Referring Provider Information Primary Care Provider: [Primary Care Provider] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Phone: [Primary Care Provider Phone] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) City: [City] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Referring Provider: [Referring Provider] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Insurance and Billing Information Primary Insurance Provider: [Primary Insurance Provider] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan Name: [Plan Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Policy ID: [Policy ID] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Group Number: [Group Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Policy Holder: [Policy Holder] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) DOB: [Policy Holder DOB] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Consent & Authorization "I consent to medical treatment and acknowledge financial responsibility." (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date: [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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