Wellivery New Medical History Form

General Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weight (kg or lbs)*
Height (cm or inches or feet + inches)*
E-Mail*
example@example.com
Reason for seeing the doctor:*
How to you learn of Wellivery?*
More Details about your concern:
When did it start? Has it happened before? What makes it better or worse?*
Patient Medical History
Please list any drug allergies*
Patient Medical History
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaNone of these
Other chronic illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications*
Healthy & Unhealthy Habits
Exercise*

Never1-2 days3-4 days5+ days
Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History*
Immunizations and date of each:*
Consent to Receive Treatment
1. I hereby authorize Wellivery doctors to use the telehealth platform for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and that my appointment may not be started or ended as intended.

3. I accept that the Wellivery doctors can contact me using interactive video sessions but that the sessions can also be conducted via regular voice communication or in-person if the technical requirements such as internet speed cannot be met.

4. I agree that my medical records can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

General Patient Information

More Details about your concern:

Patient Medical History

Patient Medical History

Healthy & Unhealthy Habits

Consent to Receive Treatment