{ "$schema": "https://ui.shadcn.com/schema/registry-item.json", "name": "patient-intake-form", "title": "Patient Intake Form", "type": "registry:block", "files": [ { "path": "packages/registry-react/blocks/patient-intake-form/PatientIntakeForm.tsx", "content": "'use client'\n\nimport * as React from 'react'\nimport {\n Activity,\n AlertTriangle,\n Building2,\n Calendar,\n Check,\n ChevronLeft,\n ChevronRight,\n CreditCard,\n Download,\n FileCheck,\n FileText,\n Lock,\n Phone,\n RotateCcw,\n ShieldCheck,\n Stethoscope,\n User,\n UserCheck,\n} from 'lucide-react'\nimport { cn } from '@/lib/utils'\nimport { Badge } from '@/components/ui/badge'\nimport { Button } from '@/components/ui/button'\nimport { Checkbox } from '@/components/ui/checkbox'\nimport { Input } from '@/components/ui/input'\nimport { Label } from '@/components/ui/label'\nimport { SectionCard } from '@/components/ui/section-card'\nimport { Select, SelectContent, SelectItem, SelectTrigger, SelectValue } from '@/components/ui/select'\nimport { Separator } from '@/components/ui/separator'\nimport { Stepper } from '@/components/ui/stepper'\nimport { Textarea } from '@/components/ui/textarea'\n\nexport interface PatientIntakeData {\n // Step 1: Personal Information\n firstName: string\n middleName: string\n lastName: string\n preferredName: string\n dob: string\n biologicalSex: string\n maritalStatus: string\n phone: string\n email: string\n streetAddress: string\n city: string\n state: string\n zipCode: string\n emergencyName: string\n emergencyRelationship: string\n emergencyPhone: string\n\n // Step 2: Medical History\n chronicConditions: string[]\n hasAllergies: boolean\n allergyDetails: string\n currentMedications: string\n pastSurgeries: string\n primaryCarePhysician: string\n clinicPhone: string\n\n // Step 3: Insurance & Billing\n insuranceCarrier: string\n memberId: string\n groupNumber: string\n policyholderName: string\n policyholderRelationship: string\n frontCardUploaded: boolean\n backCardUploaded: boolean\n\n // Step 4: Consent & Sign\n hipaaConsent: boolean\n treatmentConsent: boolean\n telehealthConsent: boolean\n signatureName: string\n signatureDate: string\n signerRole: string\n}\n\nexport interface PatientIntakeFormProps {\n initialStep?: number\n initialData?: Partial\n className?: string\n onSubmit?: (data: PatientIntakeData) => void\n onStepChange?: (step: number) => void\n}\n\nconst steps = [\n { id: 1, title: 'Personal Information', description: 'Demographics & Contact' },\n { id: 2, title: 'Medical History', description: 'Conditions & Medications' },\n { id: 3, title: 'Insurance & Billing', description: 'Coverage & Card Photos' },\n { id: 4, title: 'Consent & Sign', description: 'HIPAA & Authorization' },\n]\n\nconst CHRONIC_CONDITIONS = [\n { id: 'hypertension', label: 'Hypertension (High Blood Pressure)' },\n { id: 'diabetes', label: 'Diabetes (Type 1 or Type 2)' },\n { id: 'asthma', label: 'Asthma / Respiratory Conditions' },\n { id: 'heart_disease', label: 'Coronary Artery / Heart Disease' },\n { id: 'arthritis', label: 'Arthritis / Chronic Joint Pain' },\n { id: 'cancer', label: 'Cancer / Remission History' },\n { id: 'thyroid', label: 'Thyroid / Endocrine Disorder' },\n { id: 'anxiety_depression', label: 'Depression / Clinical Anxiety' },\n { id: 'kidney_disease', label: 'Chronic Kidney Disease' },\n { id: 'gerd', label: 'Acid Reflux / GERD' },\n]\n\nconst INSURANCE_CARRIERS = [\n { id: 'bcbs', label: 'BlueCross BlueShield' },\n { id: 'aetna', label: 'Aetna Health' },\n { id: 'cigna', label: 'Cigna Healthcare' },\n { id: 'united', label: 'UnitedHealthcare' },\n { id: 'medicare', label: 'Medicare Part A / B' },\n { id: 'medicaid', label: 'Medicaid' },\n { id: 'humana', label: 'Humana' },\n { id: 'kaiser', label: 'Kaiser Permanente' },\n { id: 'self_pay', label: 'Self-Pay (Uninsured)' },\n]\n\nconst DEFAULT_DATA: PatientIntakeData = {\n firstName: 'Eleanor',\n middleName: 'Rose',\n lastName: 'Vance',\n preferredName: 'Ellie',\n dob: '1988-10-14',\n biologicalSex: 'female',\n maritalStatus: 'married',\n phone: '(555) 234-8921',\n email: 'eleanor.vance@example.com',\n streetAddress: '742 Evergreen Terrace',\n city: 'Springfield',\n state: 'OR',\n zipCode: '97477',\n emergencyName: 'Marcus Vance',\n emergencyRelationship: 'spouse',\n emergencyPhone: '(555) 987-6543',\n\n chronicConditions: ['hypertension', 'asthma'],\n hasAllergies: true,\n allergyDetails: 'Penicillin (Anaphylaxis/hives), Sulfa antibiotics (severe skin rash)',\n currentMedications:\n 'Lisinopril 10mg PO once daily in morning, Albuterol HFA 90mcg inhaler 1-2 puffs Q4H PRN for bronchospasm, Multivitamin daily',\n pastSurgeries: 'Appendectomy (Laparoscopic, 2016), Right knee arthroscopy / meniscus debridement (2021)',\n primaryCarePhysician: 'Dr. Robert Chen, MD',\n clinicPhone: '(555) 601-2290 — Northwest Health Partners',\n\n insuranceCarrier: 'bcbs',\n memberId: 'XEH-902814891',\n groupNumber: 'GRP-44028',\n policyholderName: 'Eleanor Vance',\n policyholderRelationship: 'self',\n frontCardUploaded: true,\n backCardUploaded: true,\n\n hipaaConsent: true,\n treatmentConsent: true,\n telehealthConsent: true,\n signatureName: 'Eleanor R. Vance',\n signatureDate: '2026-08-21',\n signerRole: 'patient',\n}\n\nexport function PatientIntakeForm({\n initialStep = 1,\n initialData = {},\n className,\n onSubmit,\n onStepChange,\n}: PatientIntakeFormProps) {\n const [step, setStep] = React.useState(initialStep)\n const [, setSubmitted] = React.useState(false)\n const [intakeId] = React.useState('INTAKE-2026-8942')\n\n const [formData, setFormData] = React.useState(() => ({\n ...DEFAULT_DATA,\n ...initialData,\n }))\n\n const updateField = (key: K, value: PatientIntakeData[K]) => {\n setFormData((prev) => ({ ...prev, [key]: value }))\n }\n\n const toggleCondition = (conditionId: string, checked: boolean) => {\n setFormData((prev) => {\n const exists = prev.chronicConditions.includes(conditionId)\n if (checked && !exists) {\n return { ...prev, chronicConditions: [...prev.chronicConditions, conditionId] }\n }\n if (!checked && exists) {\n return { ...prev, chronicConditions: prev.chronicConditions.filter((id) => id !== conditionId) }\n }\n return prev\n })\n }\n\n const selectedCarrierLabel = React.useMemo(() => {\n const found = INSURANCE_CARRIERS.find((c) => c.id === formData.insuranceCarrier)\n return found ? found.label : formData.insuranceCarrier\n }, [formData.insuranceCarrier])\n\n function onStepperInput(value: number) {\n if (value < step && step !== 5) {\n setStep(value)\n onStepChange?.(value)\n }\n }\n\n function goNext() {\n if (step < 4) {\n const next = step + 1\n setStep(next)\n onStepChange?.(next)\n }\n }\n\n function handleSubmit() {\n setSubmitted(true)\n setStep(5)\n onSubmit?.({ ...formData })\n onStepChange?.(5)\n }\n\n function resetForm() {\n setStep(1)\n setSubmitted(false)\n onStepChange?.(1)\n }\n\n return (\n \n \n \n HIPAA Protected\n \n \n Form #PHI-2026-894\n \n \n }\n footer={\n
\n {step > 1 && step <= 4 ? (\n {\n const prev = step - 1\n setStep(prev)\n onStepChange?.(prev)\n }}\n >\n \n Back\n \n ) : (\n \n )}\n\n {step <= 4 ? (\n \n Step {step} of 4 — {steps[step - 1]?.title}\n \n ) : (\n Registration Complete\n )}\n\n {step < 4 ? (\n \n Continue\n \n \n ) : step === 4 ? (\n \n \n Submit Registration\n \n ) : (\n \n )}\n
\n }\n >\n {/* Stepper Navigation */}\n {step <= 4 && }\n\n {/* ================================================================= */}\n {/* STEP 1: Personal Information */}\n {/* ================================================================= */}\n {step === 1 && (\n
\n {/* PHI Notice Banner */}\n
\n \n
\n

Protected Health Information (PHI) Notice

\n

\n All legal demographics and medical history submitted through this portal are encrypted in accordance\n with federal HIPAA Omnibus rules and directly synchronized with the clinic's Electronic Health\n Record (EHR).\n

\n
\n
\n\n {/* Legal Name Section */}\n
\n

\n \n Legal Patient Identification\n

\n
\n
\n \n updateField('firstName', e.target.value)}\n placeholder=\"First name\"\n size=\"small\"\n />\n
\n
\n \n updateField('middleName', e.target.value)}\n placeholder=\"Middle name\"\n size=\"small\"\n />\n
\n
\n \n updateField('lastName', e.target.value)}\n placeholder=\"Last name\"\n size=\"small\"\n />\n
\n
\n \n updateField('preferredName', e.target.value)}\n placeholder=\"Nickname / Preferred\"\n size=\"small\"\n />\n
\n
\n
\n\n \n\n {/* Demographics Section */}\n
\n

\n \n Birth & Clinical Demographics\n

\n
\n
\n \n updateField('dob', e.target.value)}\n size=\"small\"\n />\n
\n
\n \n \n
\n
\n \n \n
\n
\n
\n\n \n\n {/* Contact & Residential Address */}\n
\n

\n \n Contact & Residential Address\n

\n
\n
\n \n updateField('phone', e.target.value)}\n placeholder=\"(555) 234-8921\"\n size=\"small\"\n />\n
\n
\n \n updateField('email', e.target.value)}\n placeholder=\"patient@example.com\"\n size=\"small\"\n />\n
\n
\n \n updateField('streetAddress', e.target.value)}\n placeholder=\"Street, Apt / Suite\"\n size=\"small\"\n />\n
\n
\n
\n \n updateField('city', e.target.value)}\n placeholder=\"City\"\n size=\"small\"\n />\n
\n
\n \n updateField('state', e.target.value)}\n placeholder=\"State / Province\"\n size=\"small\"\n />\n
\n
\n \n updateField('zipCode', e.target.value)}\n placeholder=\"ZIP code\"\n size=\"small\"\n />\n
\n
\n
\n
\n\n \n\n {/* Emergency Contact Box */}\n
\n
\n
\n \n

\n Emergency Contact (Designated Healthcare Surrogate)\n

\n
\n \n Required\n \n
\n
\n
\n \n updateField('emergencyName', e.target.value)}\n placeholder=\"Full legal name\"\n size=\"small\"\n />\n
\n
\n \n updateField('emergencyRelationship', val)}\n >\n \n \n \n \n Spouse\n Parent / Guardian\n Adult Child\n Sibling\n Friend / Relative\n Other Legal Representative\n \n \n
\n
\n \n updateField('emergencyPhone', e.target.value)}\n placeholder=\"(555) 987-6543\"\n size=\"small\"\n />\n
\n
\n
\n
\n )}\n\n {/* ================================================================= */}\n {/* STEP 2: Medical History */}\n {/* ================================================================= */}\n {step === 2 && (\n
\n {/* Chronic Conditions Checklist */}\n
\n
\n
\n \n

Chronic & Pre-Existing Health Conditions

\n
\n \n {formData.chronicConditions.length} selected\n \n
\n

\n Select any conditions diagnosed or treated in the past 5 years. If none apply, leave unchecked.\n

\n
\n {CHRONIC_CONDITIONS.map((cond) => (\n \n toggleCondition(cond.id, checked === true)}\n />\n \n {cond.label}\n \n
\n ))}\n
\n
\n\n \n\n {/* Known Allergies */}\n
\n
\n
\n \n

Known Drug, Latex, or Food Allergies

\n
\n
\n updateField('hasAllergies', checked === true)}\n label=\"I have known allergies\"\n />\n
\n
\n {formData.hasAllergies ? (\n
\n \n updateField('allergyDetails', e.target.value)}\n placeholder=\"e.g., Penicillin (Anaphylaxis), Sulfa (Severe Rash), Peanuts (Hives), Latex\"\n size=\"small\"\n />\n
\n ) : (\n

No known drug, latex, or food allergies reported.

\n )}\n
\n\n \n\n {/* Current Medications */}\n
\n
\n \n \n
\n updateField('currentMedications', val)}\n rows={3}\n placeholder=\"Include drug name, dosage, and schedule (e.g., Lisinopril 10mg once daily in AM, Metformin 500mg BID with meals)...\"\n className=\"text-xs\"\n />\n

\n Include all daily vitamins, herbal supplements, inhalers, and injections.\n

\n
\n\n \n\n {/* Past Surgeries */}\n
\n
\n \n \n
\n updateField('pastSurgeries', val)}\n rows={2}\n placeholder=\"List approximate year and procedure (e.g., Appendectomy 2016, Knee Arthroscopy 2021)...\"\n className=\"text-xs\"\n />\n
\n\n \n\n {/* Primary Care Physician */}\n
\n

Primary Care Provider / Referring Clinic

\n
\n
\n \n updateField('primaryCarePhysician', e.target.value)}\n placeholder=\"Dr. Robert Chen, MD\"\n size=\"small\"\n />\n
\n
\n \n updateField('clinicPhone', e.target.value)}\n placeholder=\"(555) 601-2290\"\n size=\"small\"\n />\n
\n
\n
\n \n )}\n\n {/* ================================================================= */}\n {/* STEP 3: Insurance & Billing */}\n {/* ================================================================= */}\n {step === 3 && (\n
\n {/* Primary Insurance Carrier */}\n
\n
\n
\n \n

Primary Medical Insurance Carrier

\n
\n \n Primary Plan\n \n
\n
\n
\n \n \n
\n
\n \n updateField('memberId', e.target.value)}\n placeholder=\"e.g. XEH-902814891\"\n size=\"small\"\n />\n
\n
\n \n updateField('groupNumber', e.target.value)}\n placeholder=\"e.g. GRP-44028\"\n size=\"small\"\n />\n
\n
\n
\n\n \n\n {/* Policyholder Details */}\n
\n

\n \n Primary Policyholder Information\n

\n
\n
\n \n updateField('policyholderName', e.target.value)}\n placeholder=\"Policyholder name\"\n size=\"small\"\n />\n
\n
\n \n updateField('policyholderRelationship', val)}\n >\n \n \n \n \n Self (Patient is Policyholder)\n Spouse\n Child / Dependent\n Other Legal Custodian\n \n \n
\n
\n
\n\n \n\n {/* Insurance Card Photo Upload Placeholders */}\n
\n
\n
\n \n

Insurance Card Photo Verification

\n
\n PNG, JPG, PDF up to 10MB\n
\n

\n Provide high-resolution photos of both front and back sides of your insurance card for optical character\n recognition (OCR) and benefit eligibility verification.\n

\n\n
\n {/* Front Card Dropzone */}\n
\n
\n
\n \n
\n
\n

Front of Insurance Card

\n

Subscriber ID & carrier logo visible

\n
\n
\n
\n {formData.frontCardUploaded ? (\n \n \n card_front_scan.jpg (2.4 MB)\n \n ) : (\n No file selected\n )}\n updateField('frontCardUploaded', !formData.frontCardUploaded)}\n >\n {formData.frontCardUploaded ? 'Replace' : 'Upload Front'}\n \n
\n
\n\n {/* Back Card Dropzone */}\n
\n
\n
\n \n
\n
\n

Back of Insurance Card

\n

Claims address & Rx BIN visible

\n
\n
\n
\n {formData.backCardUploaded ? (\n \n \n card_back_scan.jpg (1.9 MB)\n \n ) : (\n No file selected\n )}\n updateField('backCardUploaded', !formData.backCardUploaded)}\n >\n {formData.backCardUploaded ? 'Replace' : 'Upload Back'}\n \n
\n
\n
\n
\n
\n )}\n\n {/* ================================================================= */}\n {/* STEP 4: Consent & Sign */}\n {/* ================================================================= */}\n {step === 4 && (\n
\n {/* Legal Notice Accordion Box */}\n
\n
\n
\n \n

Regulatory Disclosures & Legal Notice

\n
\n \n Mandatory Acknowledgement\n \n
\n
\n
\n 1. HIPAA Notice of Privacy Practices: I\n acknowledge receipt and review of the Notice of Privacy Practices, which describes how my Protected\n Health Information (PHI) may be used and disclosed for clinical treatment, payment processing, and\n healthcare operations in strict compliance with the HIPAA Omnibus Rule (45 CFR § 164.520).\n
\n
\n 2. Informed Consent for Outpatient Treatment: I\n voluntarily authorize the clinical physicians and allied healthcare team to perform diagnostic\n evaluations, blood tests, physical examinations, and outpatient clinical care deemed medically\n necessary.\n
\n
\n 3. Assignment of Benefits & Financial Agreement:{' '}\n I assign all medical insurance benefits directly to the provider. I acknowledge that I remain\n financially responsible for copayments, deductibles, and non-covered services not adjudicated by my\n carrier.\n
\n
\n
\n\n {/* Consent Checkboxes */}\n
\n
\n updateField('hipaaConsent', checked === true)}\n className=\"mt-0.5\"\n />\n
\n \n

\n I have read, understood, and accept the HIPAA Notice of Privacy Practices and consent to electronic\n medical record management.\n

\n
\n
\n\n
\n updateField('treatmentConsent', checked === true)}\n className=\"mt-0.5\"\n />\n
\n \n

\n I authorize medical evaluation and agree to the assignment of insurance benefits to the clinical care\n provider.\n

\n
\n
\n\n
\n updateField('telehealthConsent', checked === true)}\n className=\"mt-0.5\"\n />\n
\n \n

\n I consent to virtual video consultations and automated SMS/email appointment notifications and lab\n report alerts.\n

\n
\n
\n
\n\n \n\n {/* Electronic Signature Pad */}\n
\n
\n
\n \n

Electronic Signature & Digital Certification

\n
\n \n 256-bit Certified\n \n
\n\n
\n
\n \n updateField('signatureName', e.target.value)}\n placeholder=\"e.g. Eleanor R. Vance\"\n size=\"small\"\n />\n
\n
\n \n \n
\n
\n \n updateField('signatureDate', e.target.value)}\n size=\"small\"\n />\n
\n
\n\n {/* Live Digital Signature Stamp Preview */}\n
\n
\n Legal Digital Signature Stamp\n \n \n Verified & Timestamped\n \n
\n\n
\n

\n {formData.signatureName || 'Your Signature'}\n

\n
\n\n
\n \n Signer: {formData.signatureName || 'Eleanor Vance'} ({formData.signerRole})\n \n Date: {formData.signatureDate} · Ref #SIG-49102-HIPAA\n
\n
\n
\n
\n )}\n\n {/* ================================================================= */}\n {/* STEP 5: Success / Confirmation Receipt */}\n {/* ================================================================= */}\n {step === 5 && (\n
\n
\n \n
\n\n
\n

Patient Intake Submitted Successfully

\n

\n Your new patient registration and encrypted medical disclosures have been received and queued for clinical\n triage.\n

\n
\n\n
\n Confirmation ID:\n {intakeId}\n
\n\n {/* Registration Summary Card */}\n
\n
\n
\n Patient Name:\n \n {formData.firstName} {formData.middleName} {formData.lastName}\n \n
\n
\n Date of Birth:\n \n {formData.dob} ({formData.biologicalSex})\n \n
\n
\n Primary Insurance:\n \n {selectedCarrierLabel} (ID: {formData.memberId})\n \n
\n
\n Emergency Contact:\n \n {formData.emergencyName} ({formData.emergencyPhone})\n \n
\n
\n Legal Signature:\n \n {formData.signatureName} ({formData.signatureDate})\n \n
\n
\n
\n\n {/* Action Buttons */}\n
\n \n \n Download Intake PDF\n \n \n
\n
\n )}\n \n )\n}\n", "type": "registry:block", "target": "~/components/blocks/PatientIntakeForm.tsx" } ], "dependencies": [ "lucide-react" ], "devDependencies": [], "registryDependencies": [ "https://uipkge.dev/r/react/badge.json", "https://uipkge.dev/r/react/button.json", "https://uipkge.dev/r/react/checkbox.json", "https://uipkge.dev/r/react/input.json", "https://uipkge.dev/r/react/label.json", "https://uipkge.dev/r/react/section-card.json", "https://uipkge.dev/r/react/select.json", "https://uipkge.dev/r/react/separator.json", "https://uipkge.dev/r/react/stepper.json", "https://uipkge.dev/r/react/textarea.json" ], "description": "HIPAA-compliant new patient registration and medical history questionnaire in a SectionCard. Features a 4-step Stepper (Personal Information → Medical History → Insurance & Billing → Consent & Sign), demographic inputs with biological sex and emergency contact, chronic conditions checklist with allergy details and medication textareas, insurance carrier selection with card photo upload dropzones, regulatory HIPAA disclosure accordion with electronic signature pad, and a post-submission confirmation receipt with patient ID.", "categories": [ "healthcare", "app", "forms" ] }