Patient Intake

Create a basic new patient intake form. Start with Patient Information: legal first name, last name, date of birth, biological sex dropdown (male, female, prefer not to say), gender identity as short text (optional), preferred name, email address, phone number, address, emergency contact name, emergency contact phone, and relationship to patient. Then Insurance Information: insurance provider name, member ID, group number, subscriber name (if different), subscriber date of birth. Then Medical History: current health conditions (long text, optional), list of current medications with dosages (long text, optional), known drug allergies (long text, optional), previous surgeries or hospitalizations (long text, optional), family medical history relevant to care (long text, optional), do you smoke dropdown (never, former smoker, current smoker), do you drink alcohol dropdown (never, occasionally, regularly), primary care physician name (optional). End with a section for Authorization: a required signature field, a date field, and a checkbox confirming the patient authorizes the practice to use and disclose their protected health information as necessary for treatment.