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SEWA-AIFW TeleHealth Registration
By filling out this form, I give consent that my information will be shared with the physician assigned to my consult. I also consent to and acknowledge that the telehealth session will be held via Zoom/by phone.
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* Indicates required question
Email
*
Your email
Are you able to use the Zoom application?
*
Yes
No
Name
*
Your answer
Phone Number
*
Your answer
Names of all parties (Other than Patient)present during the telehealth consult and their role /relationship):
Your answer
Age
*
Your answer
Sex
*
Female
Male
Prefer not to say
Other:
Weight
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Issue or reason for visit
*
Your answer
Medical History. (Any Surgeries, Hypertension, Diabetes, Heart problems,etc )
*
Your answer
Family history: (any of the above medical problems or others)
*
Your answer
Medications currently using
*
Your answer
Blood Sugar Readings (with fasting)
Your answer
Blood Pressure
Your answer
A1C
Your answer
Do you have a primary care doctor?
*
Yes
No
When was your last medical checkup?
*
MM
/
DD
/
YYYY
What immunizations have you had?
Your answer
Do you have a medical directive?
*
Yes
No
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