Intake Form

The nurse writes no known allergies in a box
too small for what I would enter.
Date of last procedure. Date of birth.
Do you have a living will.

I watch her hand move across the grid—
each cell a question that expects a number,
a yes or no, a single name—

the body keeps its own records:
the scar that maps a summer I can't place,
the left knee that predicts rain three days out,
my father's hands
now at the ends of my arms.

She asks if I'm in pain on a scale.
I say four—
present,
manageable.

The clock on the wall has no second hand.
Time in here moves in the administrative tense—
appointments, intervals, the allotted.

The form pauses—
a blank line that holds.

Something unentered
remains unentered.

The scar again—at the wrist—
a line the form would call minor,
if it could read it.

She asks who to call in case of.
I give a name.
The name is accurate.

The name does not describe the person.
Outside, a pigeon walks the ledge
in a preoccupied way—
continuing.

She dates the form. She signs.
She hands me a copy—

I sign where it says patient.