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Patient Representative

Patient Information

Address
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Patient's Gender

Contact Person Information (if different from patient)

Medical Conditions & History

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Medical Questions

Please answer the questions about the patient's condition in as much detail as possible. Every question requires an answer, so if you are unsure please just choose "Unsure".
Does the patient have any communicable illnesses such as HIV, Hepatitis, Tuberculosis (TB), Herpes, or any other sexually transmitted diseases?
Does the patient have, or has the patient ever had, a malignant or benign cancerous tumor?
Does the patient have hypertension (high blood pressure) or hypotension (low blood pressure)?
Does the patient currently have any bedsores?
Does the patient currently have any ulcers?
Does the patient have shortness of breath or difficulty breathing?
Does the patient currently require the use of a ventilator?
Has the patient undergone a tracheotomy?
Does the patient require suctioning to keep their airways clear?
Does the patient require the use of supplemental oxygen?
Does the patient have any metal plates or rods in their body?
Does the patient have a pacemaker?
Does the patient have a continuous-medication pump?
Does the patient have a feeding tube?
Has the patient received at least one vaccination in the past three months?

File Doctor’s Reports

Please attach any doctor’s reports, medical test results, and discharge summaries that pertain to the patient’s Medical Conditions & History.PLEASE NOTE: Large files may require extra time to upload, so after you’ve clicked “SUBMIT” below, please do not close your browser window until you’ve received the message confirming a successful submission.
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