Request edit access
Patient Intake Form
Please answer the questions below to your best ability. If you have any questions about how to answer the form, please contact us by either emailing us at dr.garyzhou@gmail.com or calling us at 754-220-6799.
Patient's Name: *
Your answer
Phone Number: *
Your answer
Email Address: *
Your answer
Address: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Age:
Your answer
Sex: *
Martial Status: *
Do You have Any of the Following Health Issues? (please check all that apply) *
Required
Do you take any medications? If yes, please list all below and the reason each was prescribed: *
Your answer
Do you have any allergies? If yes, please list all below: *
Your answer
Have you had any past surgeries? *
Your answer
When was the last time you visited a doctor? *
Your answer
When was the last time you had a vascular test? *
Your answer
When was the last time you had an electrocardiogram? *
Your answer
When was the last time you had an echo-cardiogram? *
Your answer
When was the last time you had an x-ray? *
Your answer
Are you currently pregnant? *
Do you drink/consume any of the following items? *
Required
Employer: *
Your answer
Employer's Phone Number: *
Your answer
Employer's Address: *
Your answer
Occupation: *
Your answer
In case of an emergency, please list the name and phone number of your emergency contact: *
Your answer
How did you hear about our practice? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service