# Medical Intake Form

Printable patient intake and registration form with personal, insurance, medical history, and consent sections.

> For the complete documentation index, see [llms.txt](/llms.txt). Markdown variants are available by appending `.md` to any URL or sending an `Accept: text/markdown` header. An agent skill is available at [/.well-known/agent-skills/site-skill.md](/.well-known/agent-skills/site-skill.md).



<ComponentPreview base="takumi" name="medical-intake-form" />

## Installation [#installation]

<CodeTabs>
  <TabsList>
    <TabsTrigger value="cli">
      Command
    </TabsTrigger>

    <TabsTrigger value="manual">
      Manual
    </TabsTrigger>
  </TabsList>

  <TabsContent value="cli">
    ```bash
    npx shadcn@latest add @pdfcn/takumi/medical-intake-form
    ```
  </TabsContent>

  <TabsContent value="manual">
    <Steps>
      <Step>
        Install the following dependencies:
      </Step>

      ```bash
      npm install takumi-pdf @takumi-rs/helpers
      ```

      <Step>
        Copy and paste the following code into your project.
      </Step>

      <ComponentSource src="registry/bases/takumi/blocks/medical-intake-form/medical-intake-form.tsx" base="takumi" title="components/pdf/blocks/medical-intake-form/medical-intake-form.tsx" />

      <ComponentSource src="registry/bases/takumi/blocks/medical-intake-form/medical-intake-form.types.ts" base="takumi" title="components/pdf/blocks/medical-intake-form/medical-intake-form.types.ts" />

      <ComponentSource src="registry/bases/takumi/components/theme-provider.tsx" base="takumi" title="components/pdf/theme-provider.tsx" />

      <ComponentSource src="registry/bases/takumi/lib/resolve-color.ts" base="takumi" title="lib/resolve-color.ts" />

      <ComponentSource src="registry/bases/takumi/lib/pdf-primitives.tsx" base="takumi" title="lib/pdf-primitives.tsx" />

      <ComponentSource src="registry/bases/takumi/lib/pdf-svg.tsx" base="takumi" title="lib/pdf-svg.tsx" />

      <ComponentSource src="registry/themes/professional.ts" base="takumi" title="lib/pdf-themes/professional.ts" />

      <ComponentSource src="registry/themes/primitives.ts" base="takumi" title="lib/pdf-themes/primitives.ts" />

      <ComponentSource src="registry/types/pdf-themes.ts" base="takumi" title="types/pdf-themes.ts" />

      <ComponentSource src="registry/types/pdf-components.ts" base="takumi" title="types/pdf-components.ts" />

      <Step>
        Update the import paths to match your project setup.
      </Step>
    </Steps>
  </TabsContent>
</CodeTabs>

## Usage [#usage]

```tsx
import { MedicalIntakeFormDocument } from "@/components/pdf/blocks/medical-intake-form/medical-intake-form";
```

```tsx
<MedicalIntakeFormDocument
  clinicName="Sunrise Family Medicine"
  clinicAddress="200 Health Plaza, Denver, CO 80202"
  clinicPhone="(303) 555-0180"
  accentColor="#0d9488"
/>
```

## Sections [#sections]

Every section is rendered by default and can be hidden by setting its prop to `false`.

```tsx
<MedicalIntakeFormDocument
  clinicName="Sunrise Family Medicine"
  personalInfo
  emergencyContact
  insurance
  medicalHistory
  medications
  allergies
  reasonForVisit
  consent
/>
```

| Prop               | Section                                                       |
| ------------------ | ------------------------------------------------------------- |
| `personalInfo`     | Name, date of birth, gender, phone, email, and address fields |
| `emergencyContact` | Contact name, relationship, and phone fields                  |
| `insurance`        | Provider, policy, group, and subscriber fields                |
| `medicalHistory`   | Condition checklist with allergy and medication prompts       |
| `medications`      | Medication, dosage, frequency, and prescribing doctor table   |
| `allergies`        | Allergen, reaction, and severity table                        |
| `reasonForVisit`   | Free-text area for symptoms and reason for the visit          |
| `consent`          | HIPAA authorization, treatment consent, and signature lines   |

## Props [#props]

| Prop            | Type         | Description                                                 |
| --------------- | ------------ | ----------------------------------------------------------- |
| `clinicName`    | `string`     | Clinic name shown in the header and consent text            |
| `clinicLogo`    | `string`     | Optional logo image source                                  |
| `clinicAddress` | `string`     | Address shown in the header and footer                      |
| `clinicPhone`   | `string`     | Phone number shown in the header and footer                 |
| `accentColor`   | `string`     | Theme token or CSS color used for section rules and accents |
| `theme`         | `PdfcnTheme` | Theme override for the whole document                       |