Sick Visit Intake Form

Patient Information

Full Name *

Date of Birth *

Age

Gender *

Email Address *

Phone Number *

Address *

Reason for Visit / Primary Symptoms

When did the symptoms start?

Severity of symptoms

Mild Moderate Severe

Have you had these symptoms before?

Yes No

Are symptoms getting worse?

Yes No

Mention if any other details

Reason for Visit

Reqested Medication

Reqested Dose

Mention if any other details:

Current Medications (include dosage and frequency)*

Any chronic conditions? *

Yes No

Please list any known allergies you have, along with the type of reaction if known.

Examples: Penicillin, Ibuprofen, Sulfa drugs, etc.

Reaction examples: Rash, swelling, difficulty breathing, etc.

Please enter your nearest pharmacy details:

Local pharmacy address:

Local pharmacy phone number:

Please give your consent to medical evaluation and treatment. *

Electronic Signature *

Clear Signature

Date *