Intake Form

The nurse writes no known allergies in a boxtoo 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 handsnow 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 unenteredremains 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 ledgein a preoccupied way—continuing.

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

I sign where it says patient.