Exit Medical History Form NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information. Patient information Question Title * 1. Name: Question Title * 2. Date of birth: Date Date Question Title * 3. Gender: Male Female Non-binary Prefer to self-describe (please specify) Question Title * 4. Phone number: Question Title * 5. Email address: Question Title * 6. Home address: Medical history Question Title * 7. Are you currently pregnant? No Yes Question Title * 8. Do you have any known allergies? No Yes (please specify) Question Title * 9. Have you ever had surgery? No Yes (please specify) Question Title * 10. Please list all current medications: Question Title * 11. Have you experienced any of the following medical conditions? Acid reflux Anxiety Asthma Cancer Depression Diabetes Eczema Heart attack High blood pressure Migraine headache Neurological condition Pulmonary disease Stroke Ulcers Other conditions (please specify) Done