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USA Doctor Network
USA Doctor Network
Telemedicine Made Simple

Patient Intake Form





Treatment Requested



Lifestyle Info





Personal Medical History





Acid Reflux GERD: Yes No Unknown

Acne: Yes No Unknown

Arthritis: Yes No Unknown

Asthma: Yes No Unknown

Afib: Yes No Unknown

Autoimmune: Yes No Unknown

Bleeding Disorders: Yes No Unknown

Cancer: Yes No Unknown

Congestive Heart Failure: Yes No Unknown

COPD: Yes No Unknown

Coronary Artery Disease: Yes No Unknown

Chronic Fatigue Syndrome: Yes No Unknown

Crohn's Disease: Yes No Unknown

Dementia: Yes No Unknown

Depression: Yes No Unknown

Diabetes: Yes No Unknown

Difficulty Urinating: Yes No Unknown

Eczema: Yes No Unknown

Epstein Barr Virus: Yes No Unknown

Fever Chills: Yes No Unknown

Fibromyalgia: Yes No Unknown

Gastrointestinal Disorders: Yes No Unknown

Glaucoma: Yes No Unknown

Heart Disease/Heart Attack: Yes No Unknown




Hemachromatosis: Yes No Unknown

Hepatitis: Yes No Unknown

Hernia: Yes No Unknown

Hives: Yes No Unknown

High Blood Pressure: Yes No Unknown
High Cholesterol: Yes No Unknown

HIV: Yes No Unknown

Hyperthyroidism: Yes No Unknown

Hypothyroidism: Yes No Unknown

Irritable Bowel Syndrome: Yes No Unknown

Kidney Disease: Yes No Unknown

Liver Disease: Yes No Unknown

Lung Problems: Yes No Unknown

Lupus: Yes No Unknown

Migraines: Yes No Unknown

Mononucleosis: Yes No Unknown

Multiple Sclerosis: Yes No Unknown

Nasal Polyps: Yes No Unknown

Overweight: Yes No Unknown

Parathyroid: Yes No Unknown

Psoriasis: Yes No Unknown

Psychiatric Disorders: Yes No Unknown

Rosacea: Yes No Unknown

Sarcoidosis: Yes No Unknown

Seizures: Yes No Unknown

Sickle Cell Anemia: Yes No Unknown

Sleep Apnea: Yes No Unknown

Staph Skin Infection: Yes No Unknown

Stroke: Yes No Unknown

Thrombophlebitis: Yes No Unknown

Ulcerative Colitis: Yes No Unknown

Underweight: Yes No Unknown

Vitiligo: Yes No Unknown

Other: Yes No Unknown


Family Medical History





Alcohol : Yes No Unknown

Aneurysm: Yes No Unknown

Arthritis: Yes No Unknown

Asthma: Yes No Unknown

Autoimmune: Yes No Unknown

Birth Defects: Yes No Unknown

Blood Clotting: Yes No Unknown

Cancer: Yes No Unknown



COPD: Yes No Unknown

Deep Vein Thrombosis: Yes No Unknown

Dementia: Yes No Unknown

Depression: Yes No Unknown

Diabetes: Yes No Unknown

Eye Disease: Yes No Unknown
Heart Attack: Yes No Unknown

Heart Disease: Yes No Unknown

Hemochromatosis: Yes No Unknown

High Blood Pressure: Yes No Unknown

High Cholesterol: Yes No Unknown

Kidney Disease: Yes No Unknown

Liver Disease: Yes No Unknown

Lung Disease: Yes No Unknown

Osteoporosis: Yes No Unknown

Psychiatric Disorders: Yes No Unknown

Stroke: Yes No Unknown

Thyroid Disease: Yes No Unknown

Ulcers: Yes No Unknown


Health Record

LEAVE BLANK IF THERE ARENT ANY

Medical Conditions

None.

Condition: Comment: Date Of Onset:


Drug Allergies

None.

Drug Name: Reaction:


Patient Allergies

None.

Name: Reaction:


Surgeries

None.

Surgery: Comment: Date Of Surgery:


Medications

None.

Name: Comment:




Payment Authorization

By Checking this box I authorize a (1) one time charge of $39.99 to the credit card listed in this authorization form. The payment authorization is for the service of a (1) time non refundable async telemedicine consultation with a licensed doctor in your state. Your doctor consultation may be reimbursable with your insurance provider. I certify that I’m an authorized user of this card and will not dispute this payment with my card company, so long as the transaction corresponds to the terms and conditions. You agree that we or our systems may contact you via email, text or calls if needed. Any dispute will result in my information being reported to Cardharder Verification system that other merchants use to see if the cardholder is worth working with.





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