Healthcare intake & survey templates

I take lisinopril for blood pressure and metformin for diabetes — both daily, plus an occasional ibuprofen for my knee.

It's been over 2 years — I've been having sharp pain on my lower left side when I eat anything cold.

I've been struggling with anxiety since a job change 6 months ago — it's affecting my sleep and my relationship.

Lower back, mostly on the right side — it started after I lifted furniture 3 weeks ago and hasn't improved.

I've been dealing with hormonal acne along my jawline for the past 6 months — nothing over the counter has helped.

Chronic migraines — I get them 3-4 times a month and medication only takes the edge off. My doctor suggested trying this.

I'm getting headaches after working on my computer and squinting at road signs — it's been getting worse over the past 6 months.

Yes, from CVS — I take 5 daily medications and they keep running out of my blood thinner. I need somewhere more reliable.

ACL reconstruction on my right knee — surgery was 6 weeks ago and my surgeon cleared me to start PT. I want to get back to running.

I carry all my stress in my neck and shoulders — I also have a herniated disc at L4-L5 so please avoid deep pressure on my lower back.

She's been limping on her front left paw for about a week and won't eat her dry food — she's normally very active.

She was thorough and kind but the wait was 90 minutes past my appointment time — I almost left.

I have severe dental anxiety — the hygienist was gentle but nobody asked about it beforehand or offered sedation options.

Much more convenient but the video quality dropped 3 times during the exam — my doctor couldn't clearly see the rash I was showing her.

The new medication helps with energy levels but I'm having trouble sleeping and my appetite has been off for 2 weeks.

My surgeon was great but the billing department sent me 4 different amounts for the same procedure — nobody could explain why.

The staff were kind, but I waited almost an hour with no update.

My doctor said I need a stent procedure — I want to understand the risks and how long until I can go back to playing tennis.

What's the recovery time realistically? The pamphlet says 2 weeks but I've read online that it can take up to 6 weeks for my age group.

I need to lose 30 pounds before my daughter's wedding in September — I have a bad knee so I can't do high-impact.