New Patient Medical History Form Patient Name(Required) First Last Age(Required) Email(Required) PhoneAllergies(Required)Please state none if no allergiesCurrent Medications(Required)Please state none if no medicationsBrief Medical HistoryDo you have any of the following conditions? Liver Disease or Dysfunction Kidney/Renal Disease or Dysfunction Low Blood Pressure Heart Failure or Fluid Overload Abnormal Heart Rhythm Electrolyte Imbalance Current UT/ Infection G6PD Deficiency None of the above Other Please describer other Have you had any of COVID-19 related symptoms in the last 14 days, have u been in contact with a known COVID exposure in the last 14 days, have u traveled outside of US in the last 14 days? * Yes No Δ
