Hemo-Health Medical Intake Form

Hemo-Health Medical Intake Form

HIPAA-compliant intake form for patients with hemophilia and other bleeding disorders. Please complete as much as you can on mobile or desktop; required fields will be clearly marked.
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Weight (lbs)
Current Height
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Pharmacy
Hemophilia History
Bleeding disorder type

Other
Severity
Age at Diagnosis
Do you have target joints?
If yes, which joints are affected?
History of inhibitors?
If yes, please explain
Ever tested positive for HIV or hepatitis?
Current Treatment
Current medication(s) for bleeding disorder
Do you currently have PRN/emergency doses at home?
Approximately how many PRN/emergency doses do you have at home?
Have you used any of the clot-stabilizing medications listed below?
Do you wear or carry a medical alert bracelet or medical ID?
Current treatment notes
Surgical / Dental History
Have you had any past surgeries?
Please list past surgeries and dates
Do you have any planned or upcoming surgeries?
Please explain any planned or upcoming surgeries
Do you have any upcoming dental procedures planned?
Please explain any upcoming dental procedures
Allergies & General Health
Do you have any drug allergies?
If yes, list the medications and describe your reactions
Additional Support Questions
Recent bleeding episode requiring emergency treatment?
If yes, please describe the episode
Please UPLOAD an IMAGE your Insurance Card
UPLOAD IMAGE HERE

Cancelof
Consent Section
Consent for Telemedicine

I acknowledge that I am voluntarily seeking medical care and treatment through Hemo Health for the diagnosis, evaluation, management, and treatment of hemophilia, bleeding disorders, and primary care medical needs. I understand that treatment may involve medications, clotting factor concentrates, infusion therapies, laboratory monitoring, specialty pharmacy coordination, telemedicine services, and individualized treatment plans. I understand that Hemo-Health may provide care through telemedicine services, including video visits, phone consultations, and electronic communications, and I consent to receiving medical care through telemedicine where appropriate.
Consent for Telemedicine
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Hemo-Health Medical Intake Form

Patient Information

Hemophilia History

Current Treatment

Surgical / Dental History

Allergies & General Health

Additional Support Questions

Please UPLOAD an IMAGE your Insurance Card

Consent Section