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Medical History & Consent

MEDICAL HISTORY

First Name: *
**Please Fill the First Name
Last Name:*
**Please Fill the Last Name
Address:*
**Please Fill the Patient Address
E-mail:*
**Please Fill the Patient Email
Date of Birth:*
**Please Fill the date of Birth
Phone Number:*
**Please Fill the Patient Phone

INSURANCE INFORMATION (NOT REQUIRED)

Social Security: Show/Hide
**Please Fill the Patient Security
Insurance Provider:
Insurance Policy Number:
**Please Fill the Insurance Policy Number
Insurance Co. Phone (From Back of card):
Name of Parent or Guardian if Patient is a minor:
Address (if different than patients):
Phone (If different than patients):
Patient Information:
Past Medical History: Select any of the following that you have had.
1. Have you had any problems with your heart? (Palpitations, murmur, chest pain, heart attack, etc.) * Yes No
2. Have you had any problems with blood pressure? * Yes No
3. Have you had any problems with your lungs? * (Breathing problems, cough, asthma, emphysema, bronchitis) Yes No
4. Do you have a severe cold, cough, nasal congestion, or fever now? * Yes No
5. Do you have diabetes? * Yes No If yes, how many years?
6. Do you take insulin injections? * Yes No
7. Have you had hepatitis, jaundice? * Yes No
8. Have you had any kidney or bladder problems? * Yes No
9. Have you received blood transfusions? * Yes No If so, when?
10. Have you had convulsions or seizures? * Yes No
11. Have you had psychiatric problems? * Yes No
12. Any back problems? * Yes No
13. Have you had any problems with anemia? * Yes No
14. Have you had any problems with excessive bleeding? * Yes No
15. Have you had a history of stomach ulcers/hiatal hernia/indigestion? * Yes No
16. Do you smoke? * Yes No If so, how many packs a day? How many years?
17. Do you drink alcohol? * Yes No If so, how much?
18. Any diseases in your family? * (Cancer, Muscular Dystrophy, Multiple Sclerosis, etc.) Yes No
Other:
19. Other Known Medical Issues:
Medications: [List all you are taking, the dosage (strength), and how often you take it.]
Drug Allergies :
Illicit Drug Use :
* I hereby give permission to furnish information including a psychiatric diagnosis to my insurance company. In consideration of services rendered, or to be rendered, I hereby assign and transfer to MyMedView, inc., dba Comet MD any benefits payable to or for my benefit under hospitalization, sickness, or accident coverage, to include major medical, for the payment of such services rendered.
Waiver and Release and Indemnity. Patient waives and releases any and all claims against MyMedView, Inc. resulting from possession, use, distribution, or misuse of the Donated Equipment and/or related patient information, regardless of the cause and even if caused by negligence, whether passive or active. Patient agrees not to sue MyMedView, Inc., on the basis of these waived and released claims or any other matter related to the Donated Equipment and/or related patient information. Patient will defend, indemnify, and hold MyMedView, Inc., harmless from and against any and all liability, loss, damages, claims and attorney’s fees that may be suffered, resulting directly or indirectly from the possession, use, distribution, or misuse of the Donated Equipment and/or related patient information by me or any other person.
* I agree to the terms of the Informed Consent Page