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Health and Wellness Center
CJ Lee
2023-05-30T15:54:46+08:00
Health and Wellness Center
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Consent
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I agree to the privacy policy.
We respect your privacy and will keep all the personal details that you will provide secured and confidential.
Do you agree to have the information collected in this form to be used in the patient's clinical summary report?
Name
(Required)
First
Middle
Last
Suffix
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
FEMALE
MALE
Age
(Required)
Address
(Required)
House No./Lot No./Building/Unit
Street
City/Municipality
Region
Email
(Required)
Contact Number
(Required)
Package Availed
(Required)
Requesting Physician
(Required)
Patient's Information Sheet
1. Do you have any history of the following?
(Required)
Yes
No
Please select all that applies
(Required)
Allergy
Asthma
Pulmonary Tuberculosis
Diabetes Mellitus
Coronary Artery Disease
Goiter
Dyslipidemia
Hypertension
Stroke
Cancer/Tumor
Kidney Disease
Past Surgery
None
Other illness
2. Are you taking any medication(s)?
(Required)
No
Yes
1
(Required)
Please list your medications
2
Please list your medications
3
Please list your medications
4
Please list your medications
5
Please list your medications
6
Please list your medications
3. Do you smoke cigarettes?
(Required)
No
Yes
If yes, how many cigarettes per day?
(Required)
Duration
(Required)
4. Do you drink alcoholic beverages?
(Required)
No
Yes
If yes, how frequent?
(Required)
Amount
(Required)
Please list your COVID vaccine on the space provided
1st Dose
1st Booster
2nd Dose
2nd Booster
For Women, when was your last menstruation/period?
(Required)
Signature
(Required)
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