|
Medical Intake Form
|
|
|
I am HIV+
|
I am requesting PrEP Services
|
|
Year of Diagnosis (if applicable)
|
|
|
Full Name (First, Middle, Last)
|
Preferred Name
|
|
Date of Birth
|
|
|
Sex Assigned at Birth
|
Current Sex
|
|
Gender Identity
|
Preferred Pronouns
|
|
|
|
|
Demographics
|
|
|
Address (Address, City, State, Zip Code)
|
|
|
Mailing Address (if different)
|
|
|
Phone Number
|
|
|
Email Address
|
|
|
Emergency Contact Name
|
Emergency Contact Relationship
|
|
Emergency Contact Phone Number
|
|
|
Medical History
|
|
|
Primary Care Physician:
|
Primary Care Physician Address
|
|
Primary Care Physician Phone Number
|
HIV Specialist Name & Phone Number
|
|
Current Medications (List all prescriptions/over the counter medications/Herbal Supplements
|
|
|
Allergies
|
What allergies do you have?
• • •
|
|
I use an EPI Pen for my allergies.
|
If you are allergic to medications, please list them here:
|
|
Major Medical Conditions (Please check all that Apply)
• • •
|
|
|
Other Medical Conditions
• • •
|
I have been vaccinated for Hepatitis B.
|
|
Have been vaccinated again HPV? Gardasil 9
|
|
|
Do you smoke?
|
|
|
Signature
|
Date
|
|
Staff Signature
|
Date
|
