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Patient Information (Please fill all fields)

Patient's Gender

Emergency Contact or Guardian
(If different from the patient)

Medical Conditions and History

Medical Questions

Please answer the questions about the patient's condition in as much detail as possible. Every question requires an answer, so if you are unsure please just choose "Unsure".

Does the patient have any communicable illnesses such as HIV, Hepatitis, Tuberculosis (TB), Herpes, or any other sexually transmitted diseases?
Does the patient have, or has the patient ever had, a malignant or benign cancerous tumor?
Does the patient have hypertension (high blood pressure) or hypotension (low blood pressure)?
Does the patient currently have any bedsores?
Does the patient currently have any ulcers?
Does the patient have shortness of breath or difficulty breathing?
Does the patient currently require the use of a ventilator?
Has the patient undergone a tracheotomy?
Does the patient require suctioning to keep their airways clear?
Does the patient require the use of supplemental oxygen?
Does the patient have any metal plates or rods in their body?
Does the patient have a pacemaker?
Does the patient have a continuous-medication pump?
Does the patient have a feeding tube?
Has the patient received at least one vaccination in the past three months?
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