RETURNING PATIENTS | Lipsbymatt

Medical Questionnaire for Returning Patient

Please fill out the following form

First Name

Date of Birth

Last Name

Phone

Have you been hospitalized OR Have you had any changes in your health status since last consultation, such as new diagnosis of high blood pressure, thyroid or cardiac issues or others??

Yes

Have experienced any side-effects from the medications since last consulation?

Yes

Since last consultation, was your blood pressure:

NORMAL ( under 139/89)

ELEVATED ( Over 140/90)

EXTREMELY HIGH ( over 180/100)

UNSURE, but I do not have any new symptoms since last consultation

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete, Agreed to term & condition of telemedecineView terms of use

Thanks for submitting!

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