Test Medical Exemption – New Patient Intake Form – Frontline Health Advocates | Medical Exemptions for Vaccines and Masks

Patient Form (Intake 1)

Patient Name(Required)

Patient Date of Birth(Required)

Contact Name

Contact Relationship to Patient

State of Residence

Email Address

Phone Number

Text Number

Services

Exemption Type

Exemption Timing (from Dr Visit)

Medical History Standard (Intake 2)

DOCUMENTS

Driver's License

Max. file size: 512 MB.

ID for Minor Patient if applicable - Birth Certificate or Passport

Max. file size: 512 MB.

Passport

Max. file size: 512 MB.

Any Patient Provided Form(s) - Employer or School Form

Max. file size: 512 MB.

Additional Information for Minors

School Name and Address

School Principal or Administrator Name

Medical History

Last General Physical/Pediatric Well Visit

Last Eye Exam

Last Bone Density Scan

Last Colonoscopy

Last Pap Smear

Last Mammogram

Last Menstrual Period

Number of Pregnancies and Births

Last Prostate (PSA)

Medications / vitamins / supplements taken, with doses if known

Known allergies to foods / medicines / chemicals with type of reaction

Past surgeries, with dates, if known

Past significant hospitalizations, reasons and dates if known

Nicotine use? If so, how much and how long?

Alcohol use? If so, how many drinks per day/week/month

Allergies, drugs, food and chemical sensitivities

Allergies/Sensitivities to Medications

N/A

Patient

Family History of

Other

Allergies/Sensitivities to Food

N/A

Patient

Family History of

Other

Allergies/Sensivities to Latex

N/A

Patient

Family History of

Other

Allergies/Sensitivities to Household or Personal Products

N/A

Patient

Family History of

Other

Eczema

N/A

Patient

Family History of

Other

Vaccines & Immunity

Previous vaccine injury

N/A

Patient

Family History of

Other

Allergic reaction after vaccine

N/A

Patient

Family History of

Other

Sensitivity to vaccinations

N/A

Patient

Family History of

Other

Received vaccinations in the past 4 weeks

N/A

Patient

Family History of

Other

Passive immunity due to illness or blood transfusion

N/A

Patient

Family History of

Other

Immune System Dysfunction

Cancer

N/A

Patient

Family History of

Other

Leukemia

N/A

Patient

Family History of

Other

HIV/AIDS

N/A

Patient

Family History of

Other

Autoimmune Conditions (Lupus, MS, Hashimoto, Diabetes, Rheumatoid Arthritis, Lymes)

N/A

Patient

Family History of

Other

Taken Medications that affect Immune System (last 6 months)

N/A

Patient

Family History of

Other

Received immune (gamma) globulin, blood or blood products, or antiviral drug

N/A

Patient

Family History of

Other

Chemotherapy or long-term immunosuppressive therapy(s)

N/A

Patient

Family History of

Other

Heart

Myocarditis

N/A

Patient

Family History of

Other

Pericarditis

N/A

Patient

Family History of

Other

Arrhythmia

N/A

Patient

Family History of

Other

Heart Murmur

N/A

Patient

Family History of

Other

Atrial Flutter

N/A

Patient

Family History of

Other

High/Low Blood Pressure

N/A

Patient

Family History of

Other

Elevated cholesterol

N/A

Patient

Family History of

Other

Blood/Coagulation Disorder

Long-term aspirin therapy

N/A

Patient

Family History of

Other

Bleeding Disorder (hemophelia)

N/A

Patient

Family History of

Other

Anemia

N/A

Patient

Family History of

Other

Pneumonia

N/A

Patient

Family History of

Other

Sickle cell disease

N/A

Patient

Family History of

Other

Lung

Asthma

N/A

Patient

Family History of

Other

Chronic obstructive pulmonary disease COPD

N/A

Patient

Family History of

Other

Nervous System, Brain, Emotions

Seizures/Epilepsy

N/A

Patient

Family History of

Other

Headaches/Migraines

N/A

Patient

Family History of

Other

Guillain-Barre syndrome (GBS)

N/A

Patient

Family History of

Other

Noted or documented learning/working neurodivergent (ADHD, Autism)

N/A

Patient

Family History of

Other

Bell Palsy

N/A

Patient

Family History of

Other

Anxiety/PTSD

N/A

Patient

Family History of

Other

Endocrine

Polycystic ovarian syndrome (PCOS)

N/A

Patient

Family History of

Other

Hyperthyroidism / Hypothyroidism

N/A

Patient

Family History of

Other

Addison's disease

N/A

Patient

Family History of

Other

Digestion

Constipation / Diarrhea

N/A

Patient

Family History of

Other

Celiac disease / Crohns

N/A

Patient

Family History of

Other

Colitis

N/A

Patient

Family History of

Other

Gastroesophageal reflux disease GERD

N/A

Patient

Family History of

Other

Irritable Bowel Syndrome IBS

N/A

Patient

Family History of

Other

Gallstones

N/A

Patient

Family History of

Other

Hepatitis

N/A

Patient

Family History of

Other

Ulcers

N/A

Patient

Family History of

Other

Multisystem Issues

Long-term health problems: heart, lung, kidney, or metabolic disease, asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak

N/A

Patient

Family History of

Other

Symptoms consistent with an MTHFR mutation

N/A

Patient

Family History of

Other

Multi-Systemic Inflammatory Syndrome (MIS)

N/A

Patient

Family History of

Other

Currently

Moderate illness or acutely severely ill

N/A

Patient

Family History of

Other

Pregnant and/or Breastfeeding

N/A

Patient

Family History of

Other

COVID Expanded (Intake 2+)

Covid Shots Received

Date

Maker

COVID Shot 1

COVID Shot 1 Date

COVID Shot 1 Maker

COVID Shot 2

COVID Shot 2 Date

COVID Shot 2 Maker

COVID Shot 3

COVID Shot 3 Date

COVID Shot 3 Maker

COVID Shot 4

COVID Shot 4 Date

COVID Shot 4 Maker

COVID Shot 5

COVID Shot 5 Date

COVID Shot 5 Maker

COVID Shot 6

COVID Shot 6 Date

COVID Shot 6 Maker

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