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Health Assessment Form
Health History & Declaration
Please fill out the following form
prior to ordering from our shop.
First name
Last name
Email
Date of Birth
Age
Street Address
Apt/Suite/BLDG
City
State
Postal / Zip code
Emergency Contact
Emergency Contact Phone
Physician's Name
Physician's Phone
How active are you?
Choose an option
What is your height?
Do any of your immediate family members have a history of the following conditions? Select all that apply.
Cancer
Heart Disease
Dementia
Diabetes
None of these
What is your current weight?
Have you ever been informed that your kidneys aren't functioning properly, or do you have irregular kidney function?
Choose an option
Have you ever been informed that your liver isn’t functioning properly, or do you have irregular liver function?
Choose an option
Do you have any heart or heart-related conditions?
Choose an option
Have you had any of the following surgeries?
No past surgeries
Back or Neck surgery
Heart surgery or stenting
Prostate surgery (Men only)
Hysterectomy (Female only)
Gallbladder
Appendix
Other
Do you have any of these Medical Conditions? (Check all that apply)
No Medical Problems/Conditions
Diabetes
Hypertension (high blood pressure)
Heart disease
Thyroid condition
Asthma or COPD
Anxiety or depression
HIV or AIDS
Kidney disease
Cancer
Irregular heart beat
Vascular disease (stroke
Other
Do you smoke or do you have any irregular lung function?
Choose an option
Please describe why you selected other
Do you have any current skin conditions?
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Do you have any current hormone imbalances or do you suspect any?
Choose an option
Do you currently have a Primary Care Provider?
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Have you have blood work drawn?
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Please upload most recent blood test results if you have them.
Upload File
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What Medications are you currently taking?
Have you had a general health check-up or routine physical in the past year?
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When was your last physical?
Medication Allergies
Choose an option
Medication Allergies - Other
How did you hear about us?
I acknowledge and understand that Nxt Level Mobile IV is a telemedicine clinic and does not replace the need to seek routine care with my primary care provider. In the event of an emergency please call 911.
I agree to the terms listed in the Privacy Practices.
I declare that the info I’ve provided is accurate & complete
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