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?


    If Yes, please list:

    Medications (prescription and other vitamins/supplements):

    Have you/your child ever been hospitalized?

    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


    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?


    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:



    Symptoms of menopause?

    Living Age (or age at death) List serious illnesses

    Mother Living?


    If no, age/cause at death

    Father Living?


    If no, age/cause at death

    How many siblings do you have?





    Are your siblings living?


    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



    Heart disease

    High blood pressure

    Mental Illness / Depression


    Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis…)

    Other serious illness


    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.