Completing the patient questionnaire

Save time at your first Center for Healthy Living appointment by completing the customary patient questionnaire before you arrive. The form asks for general information, such as your name, address and age, and then gathers your health history.

You only need to complete the form for your first visit.

Take your choice of two ways to fill in the form:

  • Print the form from this website, complete it by hand and then bring it to your appointment.
  • Complete and submit the form electronically through the Center for Healthy Living patient portal. The portal calls the questionnaire the “intake form.” Follow the instructions to access the form.

If you have questions, please call the Center for Healthy Living at 49-40111.

Portal Login


Purdue University, 610 Purdue Mall, West Lafayette, IN 47907, (765) 494-4600

2015 Purdue University | An equal access/equal opportunity university | Copyright Complaints | Maintained by HR Communications

If you have trouble accessing this page because of a disability, please contact Human Resources at