Personal Medical History

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Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

I. BASIC INFO

First Name

Last Name

Phone

Address

II. MEDICAL INFO

1. Has a doctor ever told you that you have (currently or in the past) any of the following health conditions?

c. Atherosclerosis (plaque buildup in arteries)

Yes

a. Diabetes (not including gestational diabetes)

Yes

i. High blood pressure

Yes

d. Stroke or TIA (Transient Ischemic Attack, also called a mini stroke)

Yes

2. Do you currently take any of the following medications?

a. Medication to lower your blood pressure

Yes

b. Medication to lower your cholesterol

Yes

c. 1 or more aspirin per day

Yes

8. How many cigarettes do you smoke per day?

1-10

11-20

21-40

41+

9. What is the total number of years you have smoked? (if 0, go to question 11)

1-10

11-25

26-40

41+

10. If you used to smoke cigarettes, how many years ago did you quit?

less than 5

5-10

11-15

15+

Please provide your physician's contact information:

First Name

Last Name

Address

Phone

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I request that 1st Choice Ultrasound call me at the telephone numbers listed above to schedule follow-up appointments.

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I acknowledge receiving the Notice of Privacy Practices

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Mail

Phone

1st Choice Ultrasound

3907 Oceanic Dr #301 Oceanside, CA 92057

(858) 397-3422

(442) 266-8060

1stchoiceultrasound@gmail.com