Intake Form

Domain: Patient Profile | Type: Custom (active) | Fields: 160

Full reference: CRM Modules Guide

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What is it?

The primary structured medical intake questionnaire. Patients complete this after booking an appointment and before their first visit with a provider.

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When It’s Completed

Patient pays for appointment (Lead → Contact)
    → Patient logs into portal
    → Completes Intake Form independently (no provider present)
    → Provider reviews before the appointment
    → Data informs the first Encounter

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What It Covers (160 fields)

Section	Content
Personal Identification	Demographics, contact info
Medical History	Past conditions, surgeries, hospitalizations
Family History	Relevant hereditary conditions
Current Medications	All medications currently taking
Allergies	Drug, food, environmental
Organ System Review	Systematic review of body systems
Lifestyle	Sleep, diet, exercise, stress
Goals	What patient wants to achieve with treatment

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Notes

• The Intake Form is completed by the patient alone — providers do not assist
• 160 fields make this the most comprehensive structured data capture point for a patient’s health history
• Data feeds directly into the provider’s pre-visit review
• Different from the Self Assessment (which is pre-booking and externally facing)

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Related Modules

Module	Relationship
Contacts	Intake linked to patient Contact
Medical History	Per-patient historical medical events
Patient Allergies	Patient’s allergy list (critical safety data)
Encounters	Provider uses Intake data to inform the visit
Patient Plans	Initial plan informed by Intake data

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Other Intake Variants

Module	Program
Stem Cell Intake	Lightweight 16-field intake for stem-cell candidates
Mindlab Intake	15-field intake for life-coaching program
Weightloss Forms	122-field intake for weight-loss program (eating habits, exercise, history)
Home Visit Info	Physical exam record for initial home visit (BHRT/stem-cell)

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Full reference: CRM Modules Guide