Intake

Prior to your initial appointment, please complete the form below.

Online Intake Form: * = required field
*First name
*Last name
Today’s Date
*Address
*City
*State
*Zip
*Home Phone
*Cell Phone or secondary phone number
*Email
*Reenter Email
Age
*Date of birth
Female/Male	Female Male
Occupation
Hours of work per week
Education
Marital Status	marital status
You live with:

Emergency contact:
*Name
Relationship
*Phone

Primary Health Care Provider:
*Name
Address
City
State
Zip
*Phone

How did you hear about me?
Referral from
Advertisement/friend/website/lecture
Other

Please list your main health concerns. List as many as you can in order of importance. Star those that are your highest priority to discuss first.

Please list current medications and dosages.
Prescription Medications:
Non-prescription Medications:
Vitamins/Herbs/Other:

Do you take or use any of the following?
Laxatives (medications or herbal)	yes no
Cortisone	yes no
Tranquilizers	yes no
Pain Relievers	yes no
Hormones	yes no
Birth Control Pill	yes no
Thyroid Medication	yes no
Antacids	yes no
Sleeping pills	yes no
Antidepressants	yes no

Please list any allergies to foods, drugs or other allergens.
Please list and describe hospitalizations and surgeries.

Please list imaging and procedures with dates (x-rays, CT, MRI, ultrasound, DEXA, mammograms, EKG, colonoscopy, etc).

Did you have childhood immunizations?	yes no

Family History: Please indicate health concerns and, if deceased, cause of death, for the following relatives.
Mother
Mother’s mother
Mother’s father
Father
Father’s mother
Father’s father

Patient Testimonial

"My son recovered from Lyme disease and improved his focus at school under the care of Dr. Wilson."

- Linda N., Middletown, NY

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Connecticut / New York
845.729.0582