patient intake form for greenfield family medicine

patient name: Sarah Okonkwo
date of birth: march 15 1988
gender: female
address: 4210 Birch Lane, apt 3B, Asheville NC 28801
phone: (828) 555-0147
email: s.okonkwo@email.com
emergency contact: James Okonkwo, husband, (828) 555-0291

insurance: BlueCross BlueShield, policy number BCB-4401882, group number GRP-7720
primary care physician: Dr. Linda Patel
referring physician: none (self-referred)

allergies: penicillin (causes rash), shellfish (anaphylaxis - carries epipen), seasonal pollen (mild, takes zyrtec)

current medications:
- metformin 500mg twice daily for type 2 diabetes, started 2022
- lisinopril 10mg daily for blood pressure, started 2023
- vitamin D 2000 IU daily, recommended by PCP
- birth control (lo loestrin fe), continuous since 2019

medical history:
- type 2 diabetes diagnosed 2022, managed with diet and metformin, A1C last check was 6.8 in january 2026
- hypertension diagnosed 2023, controlled with medication
- appendectomy 2015, no complications
- fractured left wrist 2019 from a cycling accident, fully healed

family history: father has type 2 diabetes and high cholesterol. mother had breast cancer at age 58 (in remission). maternal grandmother had Alzheimer's.

social history: non-smoker, occasional alcohol (2-3 drinks per week), exercises 3x per week (yoga, hiking), works as a graphic designer from home. no recreational drug use.

reason for visit: annual physical plus follow-up on diabetes management. also wants to discuss recurring headaches that started about 3 months ago, usually behind the right eye, happen 2-3 times per week, last about 4 hours.

vaccination status: COVID fully vaccinated plus boosters (last one sept 2025), flu shot october 2025, Tdap 2021.
