Health Screening Questionnaire for Virtual Appointments

Health Screening Questionnaire for Virtual Appointments
Name*
Email
Age
Weight
Height
What city and state do you live in?
Occupation?
Do you smoke or consume nicotine in any way?
Are you diabetic? Type 1 or 2? If yes, what is your hemoglobin A1C?
Do you have any allergies? (If yes, state your allergies)
Do you have a pacemaker or defibrillator?
Do you take blood thinners? (If yes, state which ones)
Do you take herbal supplements? (If yes, state which ones)
Do you have any history of blood clots? (If yes, explain)
Have you had any pregnancies in your life? How many?
Please mark the number of pregnancies that were in each of these categories:
Vaginal
C-Section
Miscarriage
Abortion
Ectopic
Do you have any plans for future pregnancies?
Do you have any history of breast cancer in yourself or immediate family?
Did you breastfeed your child?
Do you have any medical issues at all?
Have you had any surgeries in your life? When? Please list them (including minor surgeries) and put the date next to each surgery (Note: C-section is a surgery)
Do you have any metals in your body? (If yes, where)
What medications do you take? (Specify for what you are taking these medications for and how many mg)
A few minutes before your appointment, you will receive a link to join the video call. We ask that you are somewhere private and with enough lighting so that you may disrobe and show Dr. Nathan your areas of concern. We look forward to meeting you!

If you have any questions, please call (305) 530-8880 and request to speak with a Medical Assistant.

Appointment will be canceled if answers to the health screening questionnaire are not received at least a day before the consultation during business hours. Remember to follow the Eastern Standard Time (EST).

Thank you!
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Health Screening Questionnaire for Virtual Appointments

Please mark the number of pregnancies that were in each of these categories: