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Personal Information

First Name

Last Name

Date Of Birth

Email

Contact No

Health Card Number

Sex

Male

Female

Address

Symptoms

Respiratory Symptoms

Cough

No

Yes

Shortness of breath

No

Yes

Sore throat

No

Yes

Digestive Symptoms

Nausea

No

Yes

Vomiting

No

Yes

Diarrhea

No

Yes

Other Symptoms

Fever

No

Yes

Fatigue

No

Yes

Body aches

No

Yes

Primary Care Physician Information

Guardian Full Name

Contact Number

Email

Current Medications

Please list any medications you are currently taking

Allergies

Please list any allergies (medications, food, etc.)

Past Surgeries or Hospitalizations

Please provide details of any past surgeries or hospital stay.

Vaccination History

Date of COVID 19 vaccination

No

Yes

Date of COVID 19 vaccination Date

Date of last Booster

No

Yes

Date of last Booster Date

Chronic Diseases

Do you suffer from any chronic diseases?

No

Yes

If yes, please provide details

Family Medical History

Any known hereditary diseases in your family?

No

Yes

If yes, please provide details

Lifestyle

Do you smoke or consume alcohol?

No

Yes

If yes, please provide details

Please describe your diet and exercise routine

Acknowledgement

By submitting this form, you acknowledge and agree to the terms outlined in the Consent to Use Electronic Communication .

Full Name of Patient

Signature

Date

Health Republic

YOUR TRUSTED ONLINE PHARMACY AND HEALTHCARE PROVIDER

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