RVLA Adult Intake Form

What are your most important health concerns? Please list your health concerns or symptoms:

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Please describe if there are any accommodations our clinic can make for you (for example, magnifying glasses if you are visually impaired, assistance with filling out forms, dimming fluorescent lighting, etc.):

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Please list allergies to drugs, foods, or environmental factors and your reactions below:

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Pain relievers (aspirin, ibuprofen, etc)

Cortisone (creams or pills)

Antibiotics

Sleeping pills

Antacids

Laxatives

Are you currently taking any prescription medications, over-the-counter medications, vitamins or other nutritional/herbal supplements?

Yes

What hospitalizations, surgeries, injuries, accidents, or serious illnesses have you had?

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Many families are having a hard time. Are there additional life stressors on your family? Please check below if so.

Housing

Food

Legal/court system

Racial discrimination

Domestic violence

Employment

Medical issues in the family

Other

Black/African/African-American

Latino

Pacific Islander

Asian

White

Decline to identify

American Indian/Alaska Native/Native Hawaiian/Enrolled Citizen- please list tribe below

Prefer to self describe- please type in below

Do you have a personal or family history of the following?

No to all

Yes- please select all that apply

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

Intake Form Agreement (Review Required)

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Information and Consent for Primary Care and/or Naturopathic Care (Review Required)

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Information and Consent for Massage Therapy

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Information and Consent for Acupuncture

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HIPAA Notice of Privacy Practices (Review Required)

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