Health Screening Questionnaire for Virtual Patients

Health Screening Questionnaire for Virtual Appointments

Name

NameLast Name

Email

example@example.com

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 =

Vaginal

Abortion

Ectopic

C-Section

Miscarriage

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?

Please list them including minor surgeries and put the date next to each surgery (Note Csection 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