TeleMedicine Signup

Person 1 of 5

1) Primary Signup

2) Secondary Signups

3) Payment Details

Information on insured person(s):

Primary Person (who pays for the Premium)

*Name

*Email Address:

*Address

*Contact Phone (Including Country Code)

Medical Information of Primary Person

BASIC DETAILS

In order to enroll in the TeleMedicine membership program you do not have to provide answers to the Medical Information Section. However, it will make it easier for any physician consulting with you to have this information already accessible to him. Your medical information is saved in an encrypted form and will never be sold or shared to or with third parties. Only physicians and medical staff consulting with you have access to your medical information. We keep all medical information safe and encrypted and compliant with HIPAA. If you choose not to provide the medical information at this time, you can always log into your account and provide the information later at a time more convenient to you. If you haven't provided any medical information prior to your first consultation with a physician, the nurse preparing your consultation with the Doctor will have to collect that information before you can actually talk to the consulting physician. So please, in order to save time and to keep membership fees at a minimum, answer the questions online before using the TeleMedicine service. Thank you.

Blood Type

Date of Birth

Dust Allergies

Food Allergiess

Grass Allergies

Bermuda Grass

Timothy Grass

Mold Allergies

Weed Allergies

What is your current weight?

Lbs.

What is your current height?

Feet

Inches

What is the least you have weighed in the past 5 years?

Lbs.

What is the most you have weighed in the past 5 years?

Lbs.

Have you had recent unexplained weight gain?

Yes, No,

Have you had recent unexplained weight loss?

Yes, No,

How many hours do you sleep on average at night?

Are you frequently tired?

Yes, No,

Are you having trouble sleeping? (If yes, please explain)

Yes, No,

Have you had recent fevers, night sweats or chills?

Yes, No,

LIFESTYLE

Have you ever smoked cigarettes?

Yes, No,

How many years have you smoked?

How many packs per day?

If you have quit, what year did you quit?

Have you used tobacco in other forms (pipe, cigars, chew)?

Yes, No,

Are you exposed to 'second-hand' smoke?

Yes, No,

Do you drink alcoholic beverages?

Yes, No,

How many drinks per day?

Do you have or do others express concerns about your drinking?

Yes, No,

Do you drink coffee or tea?

Yes, No,

Do you have pets or animals?

Yes, No,

Have you lived outside the United States?

Yes, No,

Have you or your family recently experienced any life changes or unusual psychological stress?

Yes, No,

Do you exercise regularly?

Yes, No,

If so, what excercises and how often?

Excercise # 1

Excercise # 2

Excercise # 3

Excercise # 4

Excercise # 5

Excercise # 6

Excercise # 7

Excercise # 8

Excercise # 9

Excercise # 10

Please, list the names and telephone numbers of Doctors involved in your care.

Physician # 1

Physician # 2

Physician # 3

Physician # 4

Physician # 5

Are you taking any prescription medications? Yes, No (if No skip to next)

Rx Medication # 1

Rx Medication # 2

Rx Medication # 3

Rx Medication # 4

Rx Medication # 5

Rx Medication # 6

Rx Medication # 7

Rx Medication # 8

Rx Medication # 9

Rx Medication # 10

Are you taking any OTC/non-prescription medications? Yes, No (if No skip to next)

OTC Medication # 1

OTC Medication # 2

OTC Medication # 3

OTC Medication # 4

OTC Medication # 5

OTC Medication # 6

OTC Medication # 7

OTC Medication # 8

OTC Medication # 9

OTC Medication # 10

Please list any vitamins, homeopathics, or herbal medicines that you are currently taking.

Supplement # 1

Supplement # 2

Supplement # 3

Supplement # 4

Supplement # 5

Supplement # 6

Supplement # 7

Supplement # 8

Supplement # 9

Supplement # 10

Please, list any bad reactions you've experienced to any medication or supplement.

Medication/Supplement # 1

Medication/Supplement # 2

Medication/Supplement # 3

Medication/Supplement # 4

Medication/Supplement # 5

Medication/Supplement # 6

Medication/Supplement # 7

Medication/Supplement # 8

Medication/Supplement # 9

Medication/Supplement # 10

Have you had any major illnesses or surgeries? (If yes, please list them below)

Yes, No,

Condition/Surgery # 1

Condition/Surgery # 2

Condition/Surgery # 3

Condition/Surgery # 4

Condition/Surgery # 5

Condition/Surgery # 6

Condition/Surgery # 7

Condition/Surgery # 8

Condition/Surgery # 9

Condition/Surgery # 10

FAMILY HISTORY

Mother

Living Deceased

Father

Living Deceased

Maternal Grandmother

Living Deceased

Maternal Grandfather

Living Deceased

Paternal Grandmother

Living Deceased

Paternal Grandfather

Living Deceased

Brothers/Sisters (please specify)

Sibling # 1

Living Deceased

Sibling # 2

Living Deceased

Sibling # 3

Living Deceased

Sibling # 4

Living Deceased

Sibling # 5

Living Deceased

Uncles/Aunts (please specify)

Aunt/Uncle # 1

Living Deceased

Aunt/Uncle # 2

Living Deceased

Aunt/Uncle # 3

Living Deceased

Aunt/Uncle # 4

Living Deceased

Aunt/Uncle # 5

Living Deceased

Children (please specify)

Child # 1

Living Deceased

Child # 2

Living Deceased

Child # 3

Living Deceased

Child # 4

Living Deceased

Child # 5

Living Deceased

IMMUNIZATIONS

Have you had the following immunizations?

Pneumonia Vaccine

Tuberculin (TB) skin test

Diptheria/Tetanus

Hepatitis A (2 shot series)

Influenza ('flu')

BCG (to prevent TB)

Measles/Mumps/Rubella

Hepatitis B (3 shot series)

Have you ever had or tested positive for:

Hepatitis Type:

Venereal (sexually transmitted) disease