Daily Intake Questionnaire
PLEASE COMPLETE AT LEAST 12 HOURS BEFORE YOUR APPT. Please leave questions blank if not applicable. Please note that your visit will be 30-45 minutes long and we may not be able to address all issues in one visit. For any urgent issues, please contact your Primary Care Provider (PCP), go to urgent care, or call 911.
First and last name *
Your answer
Date of birth *
MM
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DD
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YYYY
Date of visit (Leave blank if unknown)
MM
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DD
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YYYY
If someone other than the patient is completing this form, please provide name of person completing form and relationship to patient.
Your answer
What is the main reason for your visit today? Please list the top 1-3 concerns you would like addressed today. *
Your answer
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