Evergreen Health

Patient Intake Form

Please complete all sections below so we can provide you with the best possible care.

Personal Info

Medical History

Review & Submit

Personal Information

Basic details for your patient record

First Name

Last Name

Date of Birth

Phone Number

Email Address

Home Address

City

State

ZIP Code

Medical History

Select any conditions that apply to you

Existing Conditions

HypertensionDiabetesAsthmaHeart DiseaseAllergiesArthritisThyroid DisorderDepressionMigrainesNone of the Above

Known Allergies

Current Medications

Current Symptoms

Describe what brought you in today

Describe Your Symptoms

Pain Level (1-10)

When Did Symptoms Begin?

Insurance Information

Your insurance and billing details

Insurance Provider

Policy Number

Group Number

Primary Subscriber

Your insurance information is encrypted and stored securely in compliance with HIPAA regulations.

By submitting this form you consent to treatment and acknowledge our privacy policy.

Evergreen Health Clinic · 2400 NW Wellness Blvd · Portland, OR 97210 · (503) 555-0100