Location

Please select your ClinCloud location

Maitland

Viera

Contact and Demographics

First Name

Middle Initial

Last Name

Phone

Email

Date of Birth

What was your sex at birth?

Male

Female

Address 1

Address 2

City

State

Zipcode

Medical History

What year did you have Angina?

What year did you have Anxiety?

What year did you have an Atrial Fibrillation?

Please specify the type of Autoimmune Diseases you have/had.

What year did you have an Autoimmune Disease?

What year did you have Bipolar?

Please specify the type of Cancer you have/had.

What year did you have Cancer?

What year did you have Celiac Disease?

What year did you have Chronic Kidney Disease?

What year did you have Clotting Disorder?

What year did you have Congestive Heart Failure?

What year did you have Crohn's Disease?

What year did you have Depression?

What year did you have Diabetes Type 1 Or 2?

What year did you have Diabetic Neuropathy?

What year did you have Eosinophilic Esophagitis?

What year did you have Esophageal Varices?

What year did you have Fatty Liver Or Cirrhosis?

What year did you have Gastroesophageal Reflux Disease (GERD) / Acid Reflux?

What year did you have Gastroparesis?

What year did you have Gout?

What year did you have Hallucinations?

What year did you have a Heart Attack?

What year did you have Hepatitis A B C?

What year did you have High Blood Pressure?

What year did you have High Cholesterol?

What year did you have HIV / AIDS / STD?

What year did you have Hyper / Hypo Thyroidism?

What year did you have IBS?

What year did you have Knee Pain?

What year did you have Memory Loss / Dementia?

What year did you have Nausea / Vomiting?

What year did you have a Pacemaker?

What year did you have Parkinson's / Tremors?

What year did you have Schizophrenia?

What year did you have Shoulder Pain?

What year did you have Stents?

What year did you have Sleep Apnea?

What year did you have a Stroke?

What year did you have Trouble Swallowing?

What year did you have Ulcerative Colitis?

What year did you have Urinary Tract Infections?

Medical Devices

Do you have any of the following medical devices?

What year did you get a AICD/Defibrillator?

What year did you get a CPAP?

What year did you get a Loop Recorder?

What year did you get a Pacemaker?

What year did you get a Spinal Cord Stimulator?

What year did you get an other medical device?

Do you have a family history of Alzheimer's?

Yes

No

Do you currently use any of the following?

Nicotine

Marijuana

CBD

Alcohol

How often?

Are you allergic to anything?

Yes

No

Please specify:

Women Only

Are you Post Menopausal?

Yes

No

What year were you Post Menopausal?

Are you Surgically Sterile?

Yes

No

What year were you Surgically Sterile?

Are you on Birth Control?

Yes

No

What year were you Birth Control?

Men Only

Do you have

Enlarged Prostate

Erectile Dysfunctions

Low Testosterone

What year did yo have Low Testosterone?

What year did yo have Erectile Dysfunctions?

What year did yo have Enlarged Prostate?

Are you currently on testosterone?

Yes

No

Surgical Procedures

What year did you have an Appendix Removal?

What year did you have a Cardiovascular Surgery: CABG / Stents / Ablation?

What year did you have your Gallbladder removed?

What year did you have a Hernia Repair?

What year did you have a Hysterectomy?

What year did you have Orthopedic Surgery?

What year did you have Sinus Surgery?

What year did you have Tubal Ligation?

What year did you have a Thyroidectomy?

What year did you have a Vasectomy (Males)?

What year did you have Weight Loss Surgery?

What other major surgeries did you have?

Medications

Please list any prescribed or over the counter medications you are currently taking.

Drug Name

Medical Diagnosis Drug is Taken For

Dosage

How Often?

Start Date

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