Medical Report Form

Medical Report Form
Patient's Full Name*
First NameLast Name
Date of Birth
MonthDayYear
Date
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number*
E-mail Address*
example@example.com
HEALTH HISTORY
Height
Weight

Please give information about patients health.

	Yes	No
Are you presently under medical care?	1	2
Do you have any drug allergies?	3	4
Do you have any food or environmental allergies?	5	6
Have you ever had tuberculosis or had a positive tuberculosis test?	7	8
Have you ever been cared for by a mental health clinician?	9	10
Have you ever restricted your eating?	11	12

Is the patient diagnosed with chronic disease?
If yes, please upload your diagnosis documents.
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FAMILY HEALTH HISTORY
Please give health information about family members.
Age In Good Health? Known Health Problems Alive?
Mother
Father
Brother
Sister
PRIVACY NOTICE
The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.
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