4LK Healthcare – Patient Intake Form

Patient & Guardian Information

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Contact Phone Number *

Please enter a valid phone number (digits only).

Responsible Parent/Guardian Email Address *

Please enter a valid email address.

Consent to be contacted by Four Lucky Kids *

Yes No

Current Symptoms – System Selection

Select all systems that are currently affecting the patient:

Infectious Disease / Fever Rash Respiratory / Lungs Cardiovascular / Heart Gastroenterology / GI Neurological / Headache / Seizure Musculoskeletal (Muscle or Joint pain) Head / Ears / Eyes / Nose / Throat

General Symptoms

Please describe the patient's symptoms

How long has the patient been having symptoms?

Has the patient had any fevers?

Yes No

How high was the fever?

How was this temperature taken?

When was the last time the patient urinated? What color was the urine?

Has the patient taken any medications?

Yes No

Please list all medications and when was the last dose?

Has anyone around the patient been sick recently?

Yes No

Please describe the illness of those around the patient.

Please describe any other symptoms the patient is experiencing.

Infectious Disease / Fever

Does the patient have a rash?

Yes No

Describe the rash:

Any recent travel?

Yes No

Where did the patient travel? Please state where in the US or country (international).

Does the patient have any pets at home?

Yes No

What types of pets/animals?

Rash

How long has the patient had the rash?

Describe the rash (location, itchy, blanches, etc.)

Any recent travel?

Yes No

Where did the patient travel? Please state where in the US or country (international).

Does the patient have any pets at home?

Yes No

What types of pets/animals?

Respiratory / Lungs

Does the patient have congestion?

Yes No

Does the patient have a runny nose?

Yes No

Does the patient have a cough?

Yes No

Is the cough getting worse?

Yes No Maybe

Is the cough productive?

Yes No

What does the product of the cough look like?

When did the cough start?

Is the patient experiencing shortness of breath?

Yes No

When is the patient experiencing shortness of breath?

Is the patient having difficulty breathing?

Yes No

When is the patient having difficulty breathing?

Is the patient currently wheezing (whistling sound when breathing)?

Yes No

When does the patient have wheezing?

Cardiovascular / Heart

Does the patient have chest pain?

Yes No

Is the chest pain reproducible by pressing on the chest?

Describe the chest pain:

Intermittent Constant Unsure

Does the patient have palpitations?

Yes No

When does the patient feel the palpitations?

Has the patient fainted?

Yes No

What was the patient doing prior to fainting?

Family History Screening

Any family history of death before age 50?

Yes No

Any family history of unexplained drowning?

Yes No

Any family history of unexplained car accident?

Yes No

Any family history of congenital or childhood cardiovascular disease?

Yes No

Please explain the disease and relationship:

Gastroenterology / GI

How long has the patient been having symptoms?

Does the patient feel nauseous?

Yes No

Please describe when the patient feels nauseous:

Has the patient been vomiting?

Yes No

When is the patient vomiting?

What does the vomit look like?

What color is the vomit?

Does the patient have diarrhea?

Yes No

How many bowel/poop movements per day?

When was the last bowel movement?

Describe what the stool looks like (color and consistency):

Does the patient have abdominal pain?

Yes No

When did the abdominal pain start?

Please describe the pain.

Is the pain constant or intermittent?

Constant Intermittent

Abdominal Region Reference

Which area(s) are affected? Select all that apply.

Does the pain move or radiate?

Yes No

Has the pain moved from one area to another? Describe.

Does it hurt to urinate?

Yes No

Please describe any other symptoms the patient is experiencing.

Neurological / Headache / Seizure

Is the patient experiencing headaches?

Yes No

Please describe the headache:

Is the headache getting better, worse, or the same since onset?

Is the headache…?

Constant Intermittent

What makes the headache better?

Is the headache worse…?

In the morning In the evening Unsure

Does the patient currently have a neurologist?

Yes No

Who is the neurologist?

Is the patient on any antiepileptics?

Yes No

List medication and dosage & frequency:

Any history of trauma/hitting head?

Yes No

How long ago?

Is the patient having any visual changes?

Yes No

Please describe the visual changes:

Does light bother the patient's eyes?

Yes No

Musculoskeletal (Muscle or Joint Pain)

Describe the location of the pain:

Describe the pain (e.g. sharp, dull, achy, constant, intermittent; if lower extremity — can the patient bear weight?):

Any history of trauma?

Yes No

How long ago was the trauma?

Has the patient seen anyone for the pain?

Yes No

Who has the patient seen for pain?

What makes the pain better?

What makes the pain worse?

Head / Ears / Eyes / Nose / Throat

Ears

Does the patient have ear drainage?

Yes No

What color is the drainage?

Is there an odor?

Yes No

Is the drainage continuous or intermittent?

Continuous Intermittent

Is there an associated fever or pain?

Yes No

Eyes

Does the patient have any eye pain?

Yes No

Nose / Sinuses

Throat / Mouth

Neck