Medical History Form

Medical History Form

Please provide accurate and detailed information about your medical history. Your health is important to us!
Patient's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Race*
Ethnicity*
Gender*

MaleFemaleOther
Contact Information
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Height (inches)*
Weight (pounds)*
Vaccine History

Please provide information about your vaccine history.
COVID-19 Vaccine*

YesNo
If yes, please provide details (Manufacturer and dates (if known))
Flu Vaccine*

YesNo
If yes, please provide details (Date)
RSV Vaccine

YesNo
Pneumonia Vaccine

YesNo
Medical History
Check the conditions that apply to you*

No known medical conditionsAllergiesAlzheimer's/ DementiaAnemiaAnxietyAsthmaArthritisBarrett's EsophagusCancer or History of CancerCeliac DiseaseColitisCrohn's DiseaseCOPD (emphysema)DepressionDiabetes (Type 1)Diabetes (Type 2)DiverticulitisEczema (Atopic Dermatitis)EndometriosisFatty Liver (NAFLD)FibromyalgiaGERD (heartburn)Gilbert's Syndrome (high bilirubin)GoutGrave's Disease or History of Grave'sHeart DiseaseHeart FailureHeart Attack (Myocardial Infarction)Hepatitis BHepatitis CHIVHyperlipidemia (high cholesterol)Hypertension (high blood pressure)hypothyroid diseasehyperthyroid diseaseHeadaches (migraine)Inflammatory Bowel DiseaseIrritable Bowel DiseaseKidney DiseaseLiver FailureLupusMultiple SclerosisMyasthenia GravisOsteoarthritisPolycystic Kidney Disease (PKD)Pulmonary FibrosisPsychiatric ConditionsRheumatoid ArthritisSarcoidosisSclerodermaSeizure DisorderSjogren'sUrinary Tract Infection (recurring)PsoriasisALS
* 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?*

YesNo
If yes, please list your known allergies
Do you have any current medications?*

YesNo
If yes, please list your current medications with dosage and date started if known
Have you had any surgeries or hospitalizations in the past?*

YesNo
If yes, please list your major surgeries or hospitalizations
Do you use tobacco or nicotine?*

CurrentPastNever
If CURRENT or PAST, please select the type:
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?*

DailyOccasionallyNever
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.)*

YesNo
If yes, please list the chronic conditions in your family
How did you hear about Antria?*

**Referred by family or friend? See belowFacebookAdvertisementPast ParticipantOther
**If referred by Family or Friend- Who referred you?
Should be Empty:

Medical History Form

Contact Information

Vaccine History

Medical History

Family Medical History