Nursing Initial Patient Intake Template
Created by
Paul Hughes
Specialty
Nurse
Last edited
10/20/2026
Uses
0 times
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About this template
A structured template for collecting core patient information during an initial healthcare visit. It covers personal details, medical and social history, current concerns, medications, provider contacts, insurance, and consent.
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Personal Information
Full Name: Arthur Pendelton
Date of Birth (DOB): 14/05/1968
Sex/Gender: Male
Address: 42 High Street, Manchester, M1 4BT
Phone: 07700 900456
Email: a.pendelton68@example.co.uk
Parent/Guardian (if minor): N/A (Adult patient)
Relationship: Spouse
Emergency Contact: Sarah Pendelton
Phone: 07700 900457
Medical History
Past Illnesses/Chronic Conditions: HTN, T2DM, mild asthma
Surgeries & Hospitalizations: Laparoscopic cholecystectomy (2015)
Allergies: Penicillin (maculopapular rash)
Previous Treatments: Physiotherapy for lumbar strain (2021)
Vaccinations: Up to date; Influenza (10/2023), COVID-19 booster (10/2023), Pneumococcal (2022)
Lifestyle and Social History
Smoking: Ex-smoker (quit 2010, 15 pack-year hx)
Alcohol Use: 6 units/week
Recreational Drug Use: Denies
Exercise: Brisk walking 30 mins 3x/week
Diet: Low-carbohydrate, diabetic diet
Occupation: Chartered Accountant
Current Health Concerns
Chief Complaint: Persistent dry cough and mild exertional SOB
Duration: 3 weeks
Associated Symptoms: Nocturnal wheeze, mild fatigue. Denies fever, haemoptysis, or chest pain.
Relevant Family History: Father: IHD (MI at age 62); Mother: T2DM, asthma
Medications & Supplements
Current Medications
- metformin (Glucophage®) 500 mg PO BID
- salbutamol (albuterol, Ventolin®) 100 mcg INH PRN
Supplements: colecalciferol (vitamin D3) 1,000 IU PO OD
Pharmacy: Boots Pharmacy, Market Street, Manchester
Primary Care & Referring Provider Information
Primary Care Provider: Dr Helen Vance, Elmwood Medical Practice
Phone: 0161 496 0123
City: Manchester
Referring Provider: Self-referred
Insurance and Billing Information
Primary Insurance Provider: Bupa UK
Plan Name: Bupa By You Comprehensive
Policy ID: BUP-98431205
Group Number: GRP-44510
Policy Holder: Arthur Pendelton
DOB: 14/05/1968
Consent & Authorization
"I consent to medical treatment and acknowledge financial responsibility."
Date: 24/05/2024
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.