Patient Intake

Welcome to Arcana’s patient intake. You can download our Intake form in PDF format or fill out the form below. You can also download our HIPPA Notice of Privacy Practices. If you will fill in our Online form below, your email will be required. After you have filled out the form below, you will be sent a copy for your records and will be contacted within 72 hours.









Are you/your child allergic to penicillin or any other drugs, food, or other substances?

YesNo

If Yes, please list:










Medications (prescription and other vitamins/supplements):










Have you/your child ever been hospitalized?
YesNo

If yes, when, where and what for?

Are you/your child being treated or have you/your child ever been treated for any of the following conditions?

Please describe any current or past medical and dental treatment not listed above

Please list any past surgeries (including dental work) and the date(s) you/your child had them

Please list any sports and/or instruments you/your child has ever played (and the level)

Please list any injuries, accidents or traumas you/your child has ever had

Any complications during the parent’s pregnancy, delivery or post-partum (back pains, infections, etc)?

Have you/your child ever used smoke/chew tobacco products, alcohol or marijuana

YesNo

If yes, explain which, how much and current use?

Water intake per day in ounces:

Number of Sodas per week

Dietary restrictions/preference:

Describe your/your child’s sports, instruments, activities, exercise routine, or level of activity:

Did you/your child receive all routine childhood vaccinations?

YesNo

If no, which shots were missed and why?

Describe any difficulties you had or your child is having in school (ie. academic, social, emotional, physical, etc.)

Number of pregnancies?

Full term:

Pre-term:

Abortions/miscarriage

Symptoms of menopause?


Living Age (or age at death) List serious illnesses

Mother Living?

YesNo

If no, age/cause at death

Father Living?

YesNo

If no, age/cause at death

How many siblings do you have?

Brothers

Ages

Sisters

Ages

Are your siblings living?

YesNo

If no, age at death

Has any member of your/your child’s family had any of the following illnesses:
(List illness and which family member)

Anemia or Blood disease

Cancer

Diabetes

Heart disease

High blood pressure

Mental Illness / Depression

Stroke

Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis…)

Other serious illness

REVIEW OF SYSTEMS

Please mark any of the following symptoms that you/your child may currently have or within the last 3 months:

By submitting, you hereby certify that to the best of my knowledge all the information you have furnished on this form is complete, true and accurate.