[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-176585-105":53,"doc-detail-176585-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","patient-intake-form","Patient Intake Form","","This document is a patient intake form designed to be completed before a first appointment. It serves to gather essential medical history and patient information to assist the care team in preparing for the visit. The form emphasizes that all provided information will be treated as protected health information (PHI) and handled in strict accordance with applicable privacy and security laws, including HIPAA, by the practice. It includes sections for active and past medical conditions, past surgeries and procedures, current medications, and drug allergies. Additionally, the form presents consent options for telehealth visits, the presence of a chaperone during sensitive exams, and authorization for the practice to leave messages regarding scheduling, billing, or test results. The document also includes a disclaimer stating it is provided by Commure Scribe, is for clinical and administrative use only, and does not constitute legal or medical advice, with the ultimate responsibility for documentation accuracy resting with the clinician and practice.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-intake-form/176585/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-intake-form/176585.png","ImageObject",442,249,{"name":88,"@type":89},"wps_ap_test_251126_0180","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-23","2026-09-02",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of this patient intake form?","Question",{"text":108,"@type":109},"The form is designed to gather essential medical history and patient information before a first appointment to help the care team prepare for the visit.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is patient information protected?",{"text":113,"@type":109},"All information provided is treated as protected health information (PHI) and handled in accordance with applicable privacy and security laws, including HIPAA, by the practice.",{"name":115,"@type":106,"acceptedAnswer":116},"What are the consent options available on this form?",{"text":117,"@type":109},"The form includes consent options for telehealth visits, the presence of a chaperone during sensitive exams, and authorization for the practice to leave messages about scheduling, billing, or test results.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},176585,1788324936,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":76},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","Please complete this form before your first appointment. Your answers help your care team prepare. Your information will be treated as protected health information (PHI) and handled in accordance with applicable privacy and security laws, including HIPAA, by this practice.\n\u000f\nACTIVE AND PAST MEDICAL CONDITIONS\nPAST SURGERIES AND PROCEDURES\nCURRENT MEDICATIONS — PRESCRIPTION\nDRUG ALLERGIES\n\u000f\n☐  Telehealth visit consent — I consent to receive care via telehealth, such as secure video or phone, as permitted by applicable state law and the practice's telehealth policy.\n☐  Chaperone — I would like a chaperone present for sensitive exams.\n☐  Authorization to leave messages — I authorize the practice to leave voicemail or secure messages about scheduling, billing, or test-result availability at the phone numbers above. I understand that detailed clinical information will be shared through secure channels whenever possible.\nProvided by Commure Scribe  |  getscribe.commure.com\nFor clinical and administrative use. This template does not constitute legal or medical advice. The clinician and practice are responsible for the accuracy and completeness of all documentation they sign.\n© 2026 Commure, Inc. All rights reserved.","cbCaitIxL7VgwMYn","https://ap.wps.com/l/cbCaitIxL7VgwMYn","docx",1468251,7,"English","# Patient Information\n# Medical Conditions and History\n## Active and Past Medical Conditions\n## Past Surgeries and Procedures\n# Current Medications and Allergies\n## Current Medications — Prescription\n## Drug Allergies\n# Consents and Authorizations\n## Telehealth Visit Consent\n## Chaperone\n## Authorization to leave messages","[{\"question\":\"What is the purpose of this patient intake form?\",\"answer\":\"The form is designed to gather essential medical history and patient information before a first appointment to help the care team prepare for the visit.\"},{\"question\":\"How is patient information protected?\",\"answer\":\"All information provided is treated as protected health information (PHI) and handled in accordance with applicable privacy and security laws, including HIPAA, by the practice.\"},{\"question\":\"What are the consent options available on this form?\",\"answer\":\"The form includes consent options for telehealth visits, the presence of a chaperone during sensitive exams, and authorization for the practice to leave messages about scheduling, billing, or test results.\"}]","Patient Intake Form | DOCX"]