WFOB

Health History & Consent – LOGiC Health

First Name *

Last Name *

Email *

Phone *

Date of Birth

Address

Street Address *

City *

State *

Country *

Postal code *

Height *

Weight *

Gender *

Blood Pressure

Current Medications *

Are there other relevant medical conditions or surgical history? *

Yes

No

List other relevant medical conditions or surgical history? *

Allergies *

Yes

No

Allergies (medications, food, environmental, etc.) *

Name of your primary care provider

Date of last in person doctor appointment

Driver’s License *

Accepted file types: JPG, JPEG, PNG, PDF. Max size: 25MB.

Has anyone your family been diagnosed with/experienced

Cancer

Blood Clotting Disorder

Stroke

Other

If other, please specify

Social History

Do you smoke/use nicotine? *

Yes

No

If yes, how much/quantity? *

Have you smoked/used nicotine in the past? *

Yes

No

If yes, how much/quantity/how long ago? *

Do you drink alcohol? *

Yes

No

If yes, how often and how much? *

Do you exercise? *

Yes

No

If yes, how often? Times per day/week/month *

Please specify other types of exercise

I confirm that I have read, understood, and consent to LOGiC Health' Policy and Practices.

Signature *

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