Patient Intake | Altana Healthcare

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Patient Intake Form

We’re happy to serve you. Please provide your information below, submit it and
one of our specialists will be in touch with you to book a session specific to
your condition and recovery journey
.
All information you provide is confidential.

First name

Last name

Email

Code

Phone

Select an Address

Date of Birth

Gender

Male

Female

Age

Occupation

Work Status

Primary Insurance Provider

Group Number:

Policy Number:

Do you use tobacco, hookah or any inhalants? *

Yes

No

Please list type, amount and frequency of use:

Do you use alcohol or any stimulants? *

Yes

No

Please list type, amount and frequency of use:

Are you taking medication - prescribed or not? *

Yes

No

Please list type, amount and frequency of use:

Please indicate all conditions you are suffering from: * Required

Alcohol Abuse

Allergies

Anemia

Asthma

Arthritis

Artificial Heart Valve

Congenital Heart Defect

Diabetes

Difficulty Breathing

Emphysema

Epilepsy

Fainting Spells

Heart Surgery

High Blood Pressure

Hip Replacement

Joint Replacement

Pacemaker

Swallowing Difficulty

Speech Difficulty

Other

I accept terms & conditions

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