Hipaa Form

Note: Fields with ( * ) are to be filled compulsory.

• 00:00:00
• Patient Name *
• Blood Group *A+A-B+B-AB+AB-O+O-Blood Group *
• Gender *MaleFemaleTransgenderGender *
• Date of Birth *
• Phone Number *
• Email *
• List out your medical issues *
• Appointment Date *
• UHID
• Weight(kg) *
• Height(cm) *
• How often do you exercsie? *Exercise impossibleAvoid exerciseLight exerciseModerate exerciseHeavy exerciseCompetitive athleteHow often do you exercsie? *
• Eating Habits VegetarianNon vegetarianPlant based dietEating Habits
• Select your illnesses

  Asthma

  Heart problem

  High BP

  Low BP

  Diabetes

  Thyroid problems

  Stroke

  Mental health problems

  None of the above

  Others
• Major/minor operations
• List any medications you take
• Family history of illnesses
• Do you smoke?

  YesNo
  Used to smoke
• Alcohol intake

  NeverMonthly or less2-4 times/week2-3 times/week
  4+ times/week
• Disabilities/Special needs

  YesNo
  Others
• Ethnic origin

  Indian/British Indian

  African

  Irish

  Carribean

  Bangladeshi

  Pakistani

  White and asian

  Others

  Prefer not to say
• Drug use

  YesNo
  Used to take drugs
• Tobacco use

  CurrentFormer
  Never
• Sign Here *
  Sign Here
• Submit