Topanga Medical — Patient Intake

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From EHR — may be outdated

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Patient Information

First Name*

Middle Name

Last Name*

Date of Birth*

Sex*

Preferred Pronouns

Marital Status

Preferred Language✓ From EHR

Interpreter Needed?✓ From EHR

YesNo

Street Address

Apt / Unit

City

State

ZIP Code

Home Phone

Mobile Phone

Email

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Emergency Contact

Name

Relationship

Phone

Email

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Insurance

Primary Insurance

Policy Number

Group Number

Member ID

Subscriber Name

Subscriber DOB

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Reason for Visit

Chief Complaint / Reason for Visit*

Current Symptoms

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Medical History

Active and past medical conditions

Problem List

No entries yet.

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Surgical History

Past Surgeries & Procedures

No entries yet.

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Current Medications

Medications

No entries yet.

⚠️

Allergies

Known Allergies

No entries yet.

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Immunization History

Vaccines

No entries yet.

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Family History

Family Medical History

Include conditions of parents, siblings, and grandparents

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Social History

Occupation

Employment Status

Living Situation

Tobacco Use

Alcohol Use

Recreational Drug Use

Exercise / Activity

Diet

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Most Recent Vitals

From your last recorded visit. You can update these if they have changed.

Height

Weight

BMI

Blood Pressure

Heart Rate

Temperature

Oxygen Saturation

Pain Score

Measurement Date

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Recent Lab Results

Most recent available results from your health record.

HbA1c

Fasting Glucose

Total Cholesterol

LDL

HDL

Triglycerides

Creatinine

eGFR

Hemoglobin

Lab Date

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