Preexisting Condition Assessment
Please complete this assessment to help us understand your health history and any preexisting medical conditions.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate if you have ever been diagnosed with any of the following conditions:
*
Diabetes
Hypertension (High Blood Pressure)
Asthma
Heart Disease
Cancer
Chronic Kidney Disease
Thyroid Disorder
Autoimmune Disorder
None of the above
Other
Please rate the severity of your current symptoms (if any):
Rows
None
Mild
Moderate
Severe
Shortness of breath
1
2
3
4
Chest pain
5
6
7
8
Fatigue
9
10
11
12
Joint pain
13
14
15
16
Swelling
17
18
19
20
Other
21
22
23
24
How long have you had the above condition(s)?
Please Select
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
Not applicable
Are you currently taking any medications for your condition(s)?
*
Yes
No
If yes, please list your current medications (name and dosage):
Do you have any allergies (medications, foods, environment)? If yes, please specify.
Family history: Has any immediate family member been diagnosed with a chronic condition?
Diabetes
Hypertension
Heart Disease
Cancer
None of the above
Other
Please provide any additional information about your health that you think is important.
Submit Assessment
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