Medical History
First Name *
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Middle Name
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Last Name *
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Date of Birth *
MM
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DD
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YYYY
Driver's License/ID Number *
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Email *
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Cell Phone *
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Address *
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City *
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Zip Code *
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I consent to being contacted regarding my recommendation expiration *
I consent to being evaluated and treated through telemedicine *
What is your primary medical problem? *
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List your other or past medical problems *
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List your past surgeries *
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List any medications you are taking *
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List any allergies to medications *
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Occupation
Job
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Alcohol Use? *
Tobacco Use? *
Family History of Heart Disease or Cancer? *
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Recent Fevers or Shortness of Breath
How would you like to have your appointment?
Please enter your FaceTime/Skype and desired date/time.
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