*****This is a simulation page and no data will be transmitted.*****
 
Choose your doctor
 
The person filling out this form is
 
 
 
 
Please read Terms and Conditions.
 

Please indicate any changes since you last saw your provider.

Medical History

Please indicate if you have had any of the following.

 

If not listed here: Please Discuss with your Physician

Anemia
Appendicitis
Arthritis
Bladder infection
Cancer (Breast)
Cancer (Colon)
Cancer (Ovarian)
Cancer (Prostate)
Cancer (Renal)
Colon Polyps
Congestive heart failure
COPD
Deep vein thrombosis (DVT)
Diabetes Mellitus
Emphysema
Esophagitis
Gallbladder problems
Glaucoma
Head injury
Heart attack
Heart murmur
Heart palpitations
Hepatitis
Hernia
High blood pressure
HIV
Phlebitis (Vein swelling)
Pleurisy
Pneumonia
Rheumatic fever
Stroke
Thyroid problems
Ulcers
Urinary tract infection (UTI)
 
 

Surgical History

Select mark all surgeries you have had.

 

If not listed here: Please Discuss with your Physician

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Medications

Please bring a list of all medications (including supplements) you are taking with you at time of visit.

 

Allergies

Are you allergic to any drug / medications?

 

If not listed here: Please Discuss with your Physician

 

Allergy

Reaction

 
 
 
 
 
 
 
 
 
 
 
 

Are you allergic to any environmental allergens?

 

If not listed here: Please Discuss with your Physician

 

Allergy

Reaction

 
 
 
 
 
 
 
 
 
 
 
 
 

Family Medical History

Please indicate which family member(s) have had these illnesses.
 

If not listed here: Please Discuss with your Physician

 
 
  Mother Father Sister Brother Daughter Son
Aneurysm
Blood/Clotting disorders
Cancer (Breast)
Cancer (Colon)
Cancer (Ovarian)
Cancer (Prostate)
Cancer (Renal)
Dementia
Diabetes Mellitus
Heart disease
Kidney disease
Leukemia
Lupus
Lymphoma
Rheumatoid arthritis
Stroke
 

Social History

Alcohol Use

Do you drink alcoholic beverages?
 
If yes, how many drinks per week?

Tobacco Use

Smoking status?
 
 
 
How many packs per day do you (or did you) smoke?
How many years have you (or did you) smoke?
Please mark other type(s) of tobacco that you use:
 
 
 

Marital Status

 
 
 
 

Occupation

 
 
 
 
 
 
 
 
 
Please read Terms and Conditions before submitting form.
 
This system and Internet site was developed to enhance communication between you and your physician’s office. By accessing or using this system and/or website (the "Site") , you agree that you have read, understand, and agree to be bound by these Terms of Use ("Terms of Use") which creates an agreement between you and University Hospitals Health System, Inc. ("University Hospitals") . If you do not wish to agree to these Terms of Use, do not access or use any part of the Site.
 

1. Modifications of Terms of Use

 
University Hospitals may change these Terms of Use at any time by posting the new or changed Terms of Use to the Site and providing a notice that the Terms of Use has changed. If you do not agree to the new or changed Terms of Use, you may stop using the Site. Your continued use of the Site after the date the new or changed Terms of Use are posted will mean you have accepted the new or changed Terms of Use.
 

2. Your Use of the Site

 
University Hospitals currently provides you with general use of and access to the Site free of charge. You recognize that medical care and treatment are complex topics requiring the services of medical professionals. The Site provides you the ability to submit medical history information to your provider only and is solely to support improved communications with your provider. The Site is designed and intended for use by adults, and is neither intended for nor designed to be used by persons under the age of 18. By using the Site, you certify that you are using or providing information through the Site on your behalf or on behalf of an individual for whom you are a guardian or have the legal right to provide such information and access that person’s health information. You also certify that the information you provide is complete, accurate, and truthful.
 

3. Not an Emergency Site

 
Communications with providers through the Site are not in "real-time", and should not be used for urgent or emergency situations. The Site does not provide any medical services. The Site does not provide emergency or urgent medical services. IF YOU BELIEVE THAT YOU ARE EXPERIENCING A MEDICAL EMERGENCY OR IF YOU NEED URGENT CARE, PLEASE CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
 

4. Use of Your Information

 
When you provide personal information through the Site, you authorize University Hospitals, its subsidiaries, its affiliated health care providers, and/or their authorized personnel to access and/or release all or any part of the information (including information regarding substance abuse, HIV testing, AIDS and psychiatric treatment) to, including, but not limited to, the appropriate healthcare insurer(s) , employers for work-related injuries, third party payor(s) , students receiving education or training in healthcare, participants in the Clinisync or other health information exchange(s) , and/or the Hospital's agent(s) , attorney(s) and/or consultant(s) for purposes including treatment of the patient, billing (or collecting payment) for services and healthcare operations including improving patient care, training or educating students, performance improvement initiatives, discharge planning, risk management, personal health record or other system-wide program(s) designed to foster interaction with patients via electronic means, and/or as required by law. You also provide University Hospitals authorization to use and distribute it in connection with University Hospitals’ operation and administration of the Site and any services related thereto. University Hospitals may use your information only as permitted by the University Hospitals Notice of Privacy Practices, these Terms of Use, and applicable law. You understand and recognize that University Hospitals, its subsidiaries, its affiliated health care providers, and/or their authorized personnel have access to medical information which may be used by UH and its research personnel for research related purposes. The use of your information for research related purposes is subject to Federal and State laws and regulations, as well as University Hospitals policies regarding research studies. You also understand and consent to disclosure of confidential medical information to a State or Federal Health Oversight Agency; an appropriate Public Health Authority; for purposes required by State and/or Federal law; in cooperation with a Law Enforcement Investigation; in cooperation with a domestic or child abuse investigation; to organ procurement organizations; and for any other permissible purpose as outlined in University Hospitals Notice of Privacy Practices.
 

5. Security of Your Information

 
The security of your information is of utmost importance to us. As such, measures have been taken to attempt to secure the communications between you, the Site, and your provider’s office. However, you understand and agree that the internet pathways are not under the control of University Hospitals or its providers and your use of the Site may result in the interception of your medical data. Additionally, we cannot guarantee the receipt of the communications sent by you.
 

6. University Hospitals Proprietary Rights

 
University Hospitals owns all proprietary rights to the Site and all content and technology related the Site. University Hospitals grants you a personal, revocable, non- assignable, and non-exclusive license to use the Site in accordance with these Terms of Use. You may not copy, modify, create derivative works of, publicly display or perform, republish, store, transmit or distribute any of University Hospitals’ proprietary material in the Site without the prior written consent of University Hospitals. Except as expressly set forth herein, you have no right, title or license to any of University Hospitals’ intellectual property.
 

7. Restrictions on Use

 
Your use of the Site and any content accessed or submitted through the Site must comply with all applicable laws, regulations and ordinances, including any laws regarding the export of data or software. Specifically you agree not to do any of the following: (a) upload to or transmit on the Site any defamatory, indecent, obscene, harassing, violent or otherwise objectionable material, or any material that is, or may be, protected by copyright, without permission from the copyright owner; (b) use the Site to violate the legal rights (including the rights of publicity and privacy) of others or to violate the laws of any jurisdiction; (c) intercept or attempt to intercept electronic mail or messages not intended for you; (d) misrepresent an affiliation or relationship with any person or organization; (e) upload to or transmit on the Site any advertisements or solicitations of business; (f) restrict or inhibit use of the Site by others, including disrupting the normal flow of dialogue, causing a screen to scroll faster than other users are able to type, or otherwise acting in a way which affects the ability of other people to engage in activities via this Site; (g) upload or otherwise transmit files that contain a virus or corrupted data; (h) collect information about others (including e-mail addresses) without their consent; (i) download a file or software or include in a message any software, files or links that you know, or have reason to believe, cannot be distributed legally over the Site or that you have a contractual obligation to keep confidential (notwithstanding its availability on the Site) ; (j) post "spam" transmit chain letters or engage in other similar activities; (k) advocate illegal activity or discuss an intent to commit an illegal act; (l) disobey any policy or regulations, including any code of conduct or other guidelines, established from time to time regarding use of this Site or any networks connected to this Site; (m) falsify or delete any author attributions, legal or other proper notices or proprietary designations or labels of the origin or source of software or other material; (n) upload to or transmit on the Site any hyperlinks to other sites that contain content that falls within the descriptions set forth in this Section; (o) access the Site other than by the interfaces provided by University Hospitals; (p) create, transmit, or display health or other information that you do not own or do not have the right to use; or, (q) engage in any other conduct that restricts or inhibits anyone's use or enjoyment of the Site, or which, as determined by University Hospitals, may harm University Hospitals or users of the Site or expose them to liability. You further agree that you will not: (i) use any device, software or routine that interferes with the proper working of the Site, (ii) attempt to interfere with the proper working of the Site, (iii) take any action that imposes an unreasonable or disproportionately large load on University Hospitals’ infrastructure, or (iv) access, reload or "refresh" transactional pages, or make any other request to transactional servers, more than once during any three (3) second interval.
 

8. Modification and Termination

 
University Hospitals may place limits on, modify, suspend or terminate all or any portion of the Site at any time without prior notice. You agree that University Hospitals shall not be liable or responsible to you or to any third party for any modification, suspension, or discontinuance of any feature or component of the Site.
 

9. Exclusion of Warranties

 
THE SITE IS PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS. UNIVERSITY HOSPITALS AND ITS SUBSIDIARIES, AFFILIATES, PARTNERS, OR SUPPLIERS ("AFFILIATES") , TO THE FULLEST EXTENT OF THE LAW, DISCLAIMS ANY AND ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, REGARDING THE SITE, INCLUDING, WITHOUT LIMITATION, ANY WARRANTY OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT.
 

10. Limitation of Liability

 
IN NO EVENT SHALL UNIVERSITY HOSPITALS OR ITS AFFILIATES BE LIABLE FOR ANY DAMAGES WHATSOEVER, INCLUDING, BUT NOT LIMITED TO, ACTUAL OR ALLEGED ADVERSE HEALTH OR MEDICAL CONSEQUENCES ARISING OUT OF OR IN CONNECTION WITH THE USE OR ACCESS OF OR THE INABILITY TO USE OR ACCESS THE SITE. UNIVERSITY HOSPITALS AND ITS AFFILIATES SHALL NOT BE LIABLE FOR ANY CONSEQUENTIAL, INCIDENTAL, INDIRECT, SPECIAL, OR PUNITIVE DAMAGES, INCLUDING, BUT NOT LIMITED TO, THOSE RESULTING FROM THE INABILITY TO ACCESS THE SITE, INTERRUPTION IN SITE, VIRUSES, DELETION OF FILES OR ELECTRONIC COMMUNICATIONS, OR INAPPROPRIATE OR UNAUTHORIZED ACCESS TO THE SITE OR INFORMATION SUBMITTED THROUGH THE SITE. THE AGGREGATE LIABILITY OF UNIVERSITY HOSPITALS, ARISING FROM OR RELATING TO THE WEBSITE (REGARDLESS OF THE FORM OF ACTION OR CLAIM, E.G. CONTRACT, WARRANTY, TORT, STRICT LIABILITY, NEGLIGENCE, OR ANY OTHER LEGAL THEORY) IS LIMITED TO $1, 000.
 

11. Law and Venue

 
These Terms of Use are governed by Ohio law. THE EXCLUSIVE VENUE FOR ANY DISPUTE RELATING TO THE SITE IS THE STATE AND FEDERAL COURTS LOCATED IN CUYAHOGA COUNTY, OHIO. YOU AND UNIVERSITY HOSPITALS CONSENT TO THE PERSONAL JURISDICTION OF THESE COURTS. Nothing in this agreement limits either party's ability to seek equitable relief.
 

12. Miscellaneous

 
For purposes of clarification, these Terms of Use are for end users of the Site. From time-to- time, University Hospitals may require licensees of components of the Site and other University Hospitals offerings to enter into a separate agreement with University Hospitals related to such components or offerings. If there is any conflict between such agreement and these Terms of Use, the separate agreement will control with respect to the specific product or Site. Failure to enforce any provision will not constitute a waiver of that provision. If any provision is found unenforceable, it and any related provisions will be interpreted to best accomplish the unenforceable provision's essential purpose. The other provisions of these Terms of Use shall remain in full force and effect.

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.