New Patient Medical History Form
Patient Name
*
Age
*
Allergies
*
Current Medications
*
Brief Medical History
*
Do you have any of the following conditions?
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Liver Disease or Dysfunction
Kidney/Renal Disease or Dysfunction
Low Blood Pressure
Heart Failure or Fluid Overload
Abnormal Heart Rhythm
Electrolyte Imbalance
Current UTI/Infection
G6PD Deficiency
None of the Above
Other
Have you had any of COVID-19 related symptoms in the last 14 days, have u been in contact with a known COVID exposure in the last 14 days, have u traveled outside of US in the last 14 days?
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Yes
No
Submit
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