Medical intake - Dark steps

New-patient intake for a family practice: demographics, insurance member ID, current medications and allergies. A dark, high-contrast version in short steps, with solid answer tiles and numbered questions.

About 6 min to complete. patient, intake, medical, insurance, dark.

Questions in this template

1. Patient name
2. Date of birth
3. Sex recorded at birth
4. Phone
5. Email
6. Do you have health insurance?
7. Insurance company
8. Member ID
9. What brings you in?
10. Do you take any medications regularly?
11. List each medication and dose
12. Have you ever been told you have...
13. Do you have any drug allergies?
14. Which medicines and what happens?

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