Error Test Patient's information Name * Name First First Middle Middle Last Last Date of Birth * Gender * MaleFemaleN/A Phone Number * Email Address * Emergency Contact Emergency Contact Name * Emergency Contact Name First First Last Last Relationship to Patient * MotherFatherGuardianSister/BrotherPartner Emergency Contact Number * Medical History Check the symptoms that you' re currently experiencing: Allergy Cardiovascular Chest Pain Diabetes Ear / Nose / Throat Eye Fever Gastrointestinal Genitourinary Hematological Lymphatic Musculoskeletal Neurological Psychiatric Respiratory Weight Gain Weight Loss OtherOther Are you currently taking any medications? * No YesYes Do you have any known medical allergies? * No YesYes Are you currently under medical treatment? * No YesYes Have you been admitted to hospital or had surgery within the last 2 years? * No Yes Do you use any kind of tobacco or have you ever used them? * No YesYes Do you use any kind of illegal drugs or have you ever used them? * No YesYes How often do you consume alcohol? * DailyWeeklyMonthlyOccasionallyNever Family History Check the conditions that apply to you or any member of your immediate family: Asthma Cancer Cardiac Disease Diabetes Epilepsy Hypertension Lung Problems Psychiatric Disorder Seizure Disorder Stroke OtherOther If you are human, leave this field blank. Next Start Over
