UMR HIPAA Medical History Form

Medical History

Please fill out all fields to be registered in our database for current and future studies.
Name*

First NameLast Name
Address*

Street Address

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth *

MonthDayYear
Date
Gender*

MaleFemale
Height
(ft) (in)
Weight
(lbs)
BMI
Are you Hispanic, Latino, or Spanish origin?*

YesNo
Race*

WhiteBlack or African AmericanNative American or Alaska NativeAsianNative Hawaiian, Samoan or Pacific IslanderOther
Are you a full time resident of Florida?*

YesNo
What type of studies are you interested in? (select all that apply)*

VaccinesBack PainHigh Blood PressureWeight LossCholesterolDiabetesHeart Attack/StrokeChronic Kidney DiseaseFatty LiverHigh TriglyceridesAlzheimer'sAlzheimer's Prevention
How did you hear about us?*
Medical History

Please review these health conditions/disease, check "Yes" if they relate to your health/medical history. Please provide dates to the best of your ability.

Respiratory

Cardiovascular

Rows	Yes	Start Date(MM/DD/YY)	Stop Date(MM/DD/YY)	Ongoing?
Coronary Heart Disease
Heart Attack (Myocardial Infarction)
Percutaneous Coronary I (Stent)
Coronary Artery Bypass Surgery
Congestive Heart Failure
Atrial fibrillation
Stroke/Cerebral vascular disease
Carotid Artery Disease
Peripheral Artery Disease
Hypertension (High Blood Pressure)
Hypercholesterolemia (High Cholesterol)
Hyperlipidemia (High Triglycerides)

Metabolic/Endocrine

Dermatology

Musculoskeletal

Gastrointestinal

Rows	Yes	Start Date(MM/DD/YY)	Stop Date(MM/DD/YY)	Ongoing?
Ulcers
Gastroesophageal Reflux Disease (GERD)
Heartburn
Irritable Bowel Disease
Crohn's Disease
Fatty Liver Disease
Hepatitis

Genitourinary

Neurological

Rows	Yes	Start Date(MM/DD/YY)	Stop Date(MM/DD/YY)	Ongoing?
Alzheimer's Disease Dementia/Cognitive Impairment
Peripheral Neuropathy
Parkinson's Disease
Migraine Headaches
Post herpetic neuralgia (Shingles)
Depression
Anxiety
Bipolar Disease
Insomnia
Post Traumatic Stress Disease

Heent

Family History

Rows	Yes	Start Date(MM/DD/YY)	Stop Date(MM/DD/YY)	Ongoing?
Alzheimer's Disease
Dementia or Cognitive Impairment
Heart Disease
Cancer

Surgical History

Rows	Yes	Date(MM/DD/YY)
Appendectomy
Prostatectomy
Cholecystectomy
Herniorrhaphy
Partial Hysterectomy
Total Hysterectomy
Tubal Ligation
Vasectomy
Pacemaker
Spinal Stimulator
Mastectomy
Coronary Stent
Knee Replacement
Hip Replacement
Kidney Transplant
Bypass Surgery
Bariatric (Sleeve, Lapband, Gastric)

Are there any other past or current medical conditions/surgeries not listed? If yes, please list them here and include dates.

Allergy History (enter dates if they apply)

If other Allergy, please explain:
Are you currently taking any medications?*

YesNo
If yes, please list current medications and dosage:
Do you drink alcohol?(If so how often?)*

DailyWeeklyMonthlyOccasionallyNever (I do not drink alcohol)
Do you use any THC/marijuana products?(If so, how often?)*

DailyWeeklyMonthlyOccasionallyNever (I do not use any THC/Marijuana products)
Do you smoke tobacco or use any nicotine products?(If so, how often?)*

DailyWeeklyMonthlyOccasionallyNever (I do not use any tobacco/nicotine products)
Have you ever been diagnosed with any type of cancer?*

YesNo
If yes, please list type of cancer and year of diagnosis:
Do you have a Primary Care Physician?

YesNo
Current Physician(s)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

Please list a contact person that may be reached in case of an emergency
Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Medical History