Clinical template
Patient Intake Form with Examples
The intake form is what a new patient fills before the first visit — on paper, a portal, or a tablet. It is not the CPP and it is not a SOAP. Staff check identity and the health card; the clinician confirms allergies and medications in the room.
Blank new-patient intake
Clinic front desk or portal. Keep clinical free text short enough that someone will actually complete it. Leave room for 'I don't know' rather than forcing a yes/no on every disease.
Patient intake form
Date: Legal name: Preferred name: Pronouns: DOB: Sex at birth / gender identity (as your clinic collects): PHN / health card # / version / expiry / province: Address: Phone: Email: Emergency contact (name, relation, phone): Preferred pharmacy (name, phone): Family physician (if this is a walk-in or specialist clinic): Interpreter needed: Y/N Language: Reason for booking / what you want from today's visit: Allergies (drug, food, latex) and what happens: Current medications (name, dose, how often) — attach a list if easier: OTC, vitamins, inhalers, injections, devices (CPAP, pump): Past medical problems (year if known): Surgeries / hospitalizations: Mental health conditions or admissions: Pregnancy / breastfeeding now: Immunizations up to date as far as you know: Y/N/unsure Tobacco / vaping: Alcohol: Recreational drugs: Occupation: Living situation: Pharmacy / privacy consents (clinic circle of care; optional research; portal account): How we may contact you (phone, voicemail, email, text) — patient initials: Signature / date / SDM if signing for a minor or incapable adult:
Fictional patients
The filled example is made-up. Intake forms collect personal health information. Store them under the same privacy rules as the chart. Do not use an intake form as consent to disclose records to an employer or insurer — that is a separate medical release.
What staff verify before the clinician walks in
- Identity and health-card eligibility for the visit type.
- Emergency contact is a reachable number, not a blank line.
- Allergy line is not empty — 'none known' is an answer; a skip is not.
- Pharmacy fax/phone if the clinic will send prescriptions today.
- Consents that your privacy policy actually requires (voicemail, email, portal).
- For pediatrics: accompanying adult and their relationship; custody notes if already on file.
Vitals, height, and weight are usually taken at this visit, not on the paper form. Point the medical assistant at the vital signs template. Do not ask the patient to self-report blood pressure as if it were a diagnosis.
Intake vs medical history vs the first SOAP
| Document | Author | Job |
|---|---|---|
| Intake form | Patient (or caregiver) | Demographics, contacts, a first-pass problem and med list, communication consent |
| Medical history / CPP | Clinician | Verified standing history the rest of the chart will trust |
| First SOAP | Clinician | Today's reason for visit, exam, assessment, plan |
Copying the intake form verbatim into the CPP without asking about the blank surgery line is how a mesh hernia repair never appears. Treat the form as a checklist for the interview.
Example — filled clinic intake
New family-practice patient
34-year-old man, Montréal. Paper form scanned to chart. Fictional.
Date: 2026-08-26 Legal name: Lucas Bergeron Preferred: Luc Pronouns: he/him DOB: 1992-04-09 PHN: [on file] QC Address / phone / email: on file. Emergency contact: Marie Bergeron (spouse) 514-555-0148 Pharmacy: Jean Coutu, Rue Saint-Denis. No FP previously (walk-in only). Interpreter: no. Reason for booking: 'Need a family doctor. Repeat for my puffer and a lump on my neck I noticed last month.' Allergies: none known. Medications: salbutamol 100 mcg 2 puffs PRN (uses a few times a week). No other Rx. Vitamin D 1000 IU daily. No CPAP/pump. Past problems: childhood asthma, still uses puffer. No diabetes, no heart disease. Surgeries: none. Hospital: once as child for asthma, year unknown. Mental health: none listed. Pregnancy: n/a. Tobacco: never. Alcohol: 1–2 beers on weekends. Other drugs: none. Occupation: cook. Lives with spouse. Contact: OK to leave voicemail; no email for results. Signed. Staff checklist: card valid, allergy line complete, pharmacy phone on file, vitals to MA (see vitals sheet). Clinician to confirm neck lump history and asthma control — intake is not the assessment.
Privacy on the form itself
Collect what you need to treat and bill. A new-patient form that asks for a social insurance number, employer claim numbers, or a blanket 'share my record with anyone in the clinic group forever' is the wrong document. Circle-of-care sharing inside the treating team is different from a medical release to a third party. Portal and email consent should be optional and specific.
Turn the first visit into a usable chart
Scribeberry can draft the first SOAP and a structured history from the intake conversation. You still verify the form against what the patient says in the room. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What should a patient intake form include?
Identity and health-card details, contacts, pharmacy, reason for the visit, allergies, medications including OTC and devices, major past history, and the communication/privacy consents your clinic actually uses. Vitals are usually measured, not self-reported on the form.
Is the intake form part of the legal chart?
Yes, once you accept it. Scan or keep the portal PDF. Correct errors in the CPP rather than leaving a wrong allergy on a handwritten page that nobody rereads.
Can intake be done online before the visit?
Yes, if the portal is appropriate for health information and someone still checks the health card and allergies on arrival. Empty mandatory fields that force 'none' are worse than allowing 'unsure'.
Does Scribeberry fill intake forms?
Scribeberry drafts clinical notes and can auto-fill many clinical forms from the visit. A patient-facing intake questionnaire still belongs in your portal or paper pack. After the visit, generate the history and SOAP from what was said, then edit.
Templates
