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

Patient Name:*

Date of Birth:*

Patient Email Address:*

Patient Phone Number:*

Please upload a photo of your drivers license:*

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 512 MB.

Use this space to upload additional files. Passport if traveling, birth certificate for any minors.

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 512 MB.

Other: Forms, Additional IDs or Documents

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 512 MB.

Additional information for schools: please include name and administrator/principal of the school you are attending.

Medications/vitamins/supplements taken, with doses if known:*

Allergies to foods or medicines with type of reaction:*

Do you smoke? If so, how much and how long?*

Do you drink? If so, how many times per week, and how many drinks per day?*

Do you have any other medical conditions? Please explain.*

When was your last colonoscopy?*

When was your last general physical?*

When was your last eye exam?*

When was your last pap smear?*

When was your last mammogram?*

When was your last bone density scan?*

Women: Last menstrual period*

Past surgeries, with dates, if known:*

Past significant hospitalizations, reasons and dates if known:*

Anemia? If so, please state relationship to patient.*

Asthma? If so, please state relationship to patient.*

Anesthesia reaction? If so, please state relationship to patient.*

Bleeding disorder? If so, please state relationship to patient.*

Cancer? If so, please state relationship to patient and type.*

Diabetes (I or II)? If so, please state relationship to patient and type.*

Elevated Cholesterol? If so, please state relationship to patient.*

Heart Attack? If so, please state relationship to patient and age.*

Heart disease? If so, please state relationship to patient.*

Psychological disorders? If so, please state relationship to patient.*

Early/unexpected death? If so, please state relationship to patient.*

Thyroid disease? If so, please state relationship to patient.*

Other? If so, please explain and state relationship to patient.*

Signature*

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Step 1: Patient Intake Form