New Patient Intake Assessment (Adult, Internal Medicine)

Date/Time: [Encounter date and time]

Provider: [Provider name and credentials]

Location/Setting: [Clinic location / telehealth platform]

Visit Type: New patient intake assessment

Data Sources: [patient / family or caregiver / outside records / pharmacy / prior EHR / health information exchange] (Select all that apply; specify which records and dates when known.)

History Reliability: [Reliability and limitations] (Note barriers such as limited historian, language needs, cognitive impairment, or records pending.)

Chief Concern

[Patient's stated reason(s) for visit] (One to two lines. Use direct quotes selectively for key phrases. If multiple concerns, list as a brief agenda ordered by urgency or patient priority.)

History of Present Illness

[Orienting one-liner] (Optional: age, salient history, and reason for visit.)

[Agenda addressed today]

[Problem-focused narratives for each active concern] (For each concern: describe onset, course, severity, triggers, associated symptoms, functional impact, pertinent positives and negatives actually assessed, prior evaluations and treatments with response, and relevant recent events. If establishing care primarily, explain why now and what was prioritized. If key details not obtained, state why and how they will be obtained.)

Past Medical History

• [Chronic condition — approximate onset/diagnosis year; current status/complications] (Repeat for each condition.)
• [Major hospitalizations or significant infections with year and context]
• [Clinically relevant psychiatric history, factually documented]
• [Unverified conditions from external sources] (Mark as unverified; records requested.)

Surgical and Procedural History

• [Surgery/procedure — year; laterality if relevant]
• [Implanted devices and status]
• [Transfusion history] (Include if relevant.)

Allergies

(Safety-critical: this section must always be present.)

• [Allergen — reaction type; severity; date or "unknown"] (Include drug allergies and clinically relevant non-drug allergies such as latex, contrast, foods.)
• [No known drug allergies — patient asked and denies / Unknown — patient unsure; pharmacy or records to be obtained with mitigation plan] (Use one of these if no allergies identified or status unknown.)

Medications

(Safety-critical: this section must always be present.)

Reconciled medication list:

• [Medication name — dose; route; frequency; indication; adherence status] (Flag high-risk medications: anticoagulants, insulin, opioids, sedatives. Repeat for each medication.)

Reconciliation source(s): [medication bottles / pharmacy printout / external records / patient recall]

Reconciliation actions: [Medications started, stopped, continued, or refilled with rationale]

Verification status: [complete / incomplete] (If incomplete, state what remains and the follow-up plan.)

Family History

• [First-degree relative — condition; age at diagnosis or death if known] (Focus on conditions affecting risk: premature cardiovascular disease, stroke, diabetes, CKD, hereditary cancers, clotting disorders.)
• [Not assessed today] (Use only if not addressed this visit.)

Social History

• Tobacco/nicotine: [Type; quantity; duration; readiness to quit]
• Alcohol: [Type; quantity; pattern]
• Living situation: [Household composition; support network]
• Substance use: [Type; frequency; route] (Include if relevant.)
• Occupation/exposures: [Job role; hazards] (Include if assessed.)
• Diet/exercise/sleep: [Brief summary] (Include if assessed.)
• Sexual history and reproductive planning: [As appropriate] (Include if assessed.)
• SDOH screening: [Food insecurity / housing / transportation / interpersonal safety findings] (Include if assessed.)

Preventive Care and Health Maintenance

• Immunizations: [Status with dates; gaps identified] (Distinguish patient-reported vs confirmed.)
• Cancer screening: [Colorectal / breast / cervical / lung — modality, date, result, next due]
• Cardiometabolic screening: [BP trend; lipids; diabetes screening — last done, next due]
• Infectious disease screening: [HIV / hepatitis / TB — last done, results] (Include as appropriate.)
• Bone health: [Risk assessment / DXA status] (Include if applicable.)
• Mental health/substance use screening: [Tools used and results] (Include if performed.)

Review of Systems

(Include only if a targeted or comprehensive ROS was performed. Omit section entirely if not performed.)

• [System: pertinent positives and negatives actually reviewed] (Document problem-focused findings relevant to differential or risk. Avoid global negative statements unless complete ROS was conducted.)

Vitals

BP: [Value] (Note if repeated, position, or context.) HR: [Value] RR: [Value] Temp: [Value] SpO2: [Value]

Weight: [Value] Height: [Value] BMI: [Value] Pain: [Score] (Include pain if relevant.)

Physical Examination

(Document only systems actually examined. Note limitations if exam was partial due to time, patient preference, or telehealth.)

• General: [Appearance and distress]
• HEENT: [Findings]
• Neck: [Findings]
• Cardiovascular: [Rate, rhythm, murmurs, edema]
• Respiratory: [Effort, breath sounds]
• Abdomen: [Findings]
• MSK: [Findings]
• Neuro: [Findings]
• Skin: [Findings]
• Psych: [Affect, cognition, behavior]

Data Reviewed

Reviewed today: [Labs, imaging, ECGs, external records — test, date, key findings]

Ordered today: [Laboratory tests, imaging, other studies ordered]

Assessment and Plan

Problem list summary: [Active problems, separating those addressed today from chronic problems acknowledged but deferred]

1) [Problem/Diagnosis — highest priority]

Assessment: [Current status and severity with supporting evidence; working diagnosis; differential if uncertainty exists]

Plan: [Diagnostics ordered; therapeutic changes with dose and rationale; nonpharmacologic recommendations; referrals with clinical question; counseling points; follow-up interval and return precautions] (Use action verbs: order, start, stop, continue, adjust, refer. Document risk-related decisions explicitly.)

2) [Problem/Diagnosis — next priority]

Assessment: [As above]

Plan: [As above] (Repeat for each problem addressed, in decreasing priority.)

Deferred Problems

• [Chronic problem acknowledged but not addressed — reason for deferral and planned follow-up]

Preventive Care Plan

• [Gaps identified and actions taken today]
• [Vaccines administered / offered / declined] (Document counseling if declined.)
• [Screening tests ordered or deferred with rationale]

Medication Reconciliation Summary

[Confirm list verified and updated; key discrepancies resolved; outstanding verification needs and follow-up plan]

Care Coordination

• [Outside records requested — what and from where]
• [Referrals placed — specialty and clinical question]
• [Follow-up plan — timeline and how results will be communicated to patient]