Patient Intake and History Form - Northwell Health 2026

1. Click ‘Get Form’ to open the Patient Intake and History Form in the editor.
2. Begin by entering your personal information at the top of the form, including your name and date of birth.
3. In the 'Past Medical History' section, check all applicable conditions you have now or have had in the past. Be thorough to ensure accurate medical records.
4. For 'Surgery and Hospitalization History', provide details about any surgeries or hospitalizations, including reasons and dates if available.
5. Complete the 'Family History' section by indicating any relevant medical conditions that family members may have experienced.
6. Fill out the 'Social History' section, detailing your living situation, occupation, smoking history, alcohol consumption, and exercise habits.
7. List any current medications in the 'Current Medications' section. Include vitamins and supplements for a comprehensive overview.
8. Describe your reason for visiting today and complete the pain assessment by circling relevant options.
9. Finally, review all sections for accuracy before signing at the bottom of the form.

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