Medical History Form
Please provide accurate and detailed information about your medical history. Your health is important to us!
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Other
Gender
*
Male
Female
Other
Contact Information
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Height (inches)
*
Weight (pounds)
*
Vaccine History
Please provide information about your vaccine history.
COVID-19 Vaccine
*
Yes
No
If yes, please provide details (Manufacturer and dates (if known))
Flu Vaccine
*
Yes
No
If yes, please provide details (Date)
RSV Vaccine
Yes
No
Pneumonia Vaccine
Yes
No
Medical History
Check the conditions that apply to you
*
No known medical conditions
Allergies
Alzheimer's/ Dementia
Anemia
Anxiety
Asthma
Arthritis
Barrett's Esophagus
Cancer or History of Cancer
Celiac Disease
Colitis
Crohn's Disease
COPD (emphysema)
Depression
Diabetes (Type 1)
Diabetes (Type 2)
Diverticulitis
Eczema (Atopic Dermatitis)
Endometriosis
Fatty Liver (NAFLD)
Fibromyalgia
GERD (heartburn)
Gilbert's Syndrome (high bilirubin)
Gout
Grave's Disease or History of Grave's
Heart Disease
Heart Failure
Heart Attack (Myocardial Infarction)
Hepatitis B
Hepatitis C
HIV
Hyperlipidemia (high cholesterol)
Hypertension (high blood pressure)
hypothyroid disease
hyperthyroid disease
Headaches (migraine)
Inflammatory Bowel Disease
Irritable Bowel Disease
Kidney Disease
Liver Failure
Lupus
Multiple Sclerosis
Osteoarthritis
Polycystic Kidney Disease (PKD)
Pulmonary Fibrosis
Psychiatric Conditions
Rheumatoid Arthritis
Sarcoidosis
Scleroderma
Sjogren's
Urinary Tract Infection (recurring)
Psoriasis
ALS
* Other conditions not listed above:
If YES to Cancer, please list date of diagnosis and type of cancer below
Do you have any known allergies?
*
Yes
No
If yes, please list your known allergies
Do you have any current medications?
*
Yes
No
If yes, please list your current medications with dosage and date started if known
Have you had any surgeries or hospitalizations in the past?
*
Yes
No
If yes, please list your major surgeries or hospitalizations
Do you use tobacco or nicotine?
*
Current
Past
Never
If CURRENT or PAST, please select the type:
Please Select
Cigarette
Chewing tobacco
Vape
If Current or Past tobacco/nicotine use, please enter what age you were when you started, age when quit (if applicable), and how much you use/used a day.
Do you drink Alcohol?
*
Daily
Occasionally
Never
Please enter age started using alcohol, age when quit (if applicable) and number of drinks per day.
Family Medical History
Do you have any family history of chronic conditions? (Cancer, Diabetes, Heart Disease, etc.)
*
Yes
No
If yes, please list the chronic conditions in your family
How did you hear about Antria?
*
**Referred by family or friend? See below
Facebook
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Past Participant
Other
**If referred by Family or Friend- Who referred you?
Submit
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