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Afrimedical Support System

Become a Member

Afrimedical Support System

Home
About
Medical Services
Membership
Contact

Become a Member

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New Patient Questionnaire

Jobs - Website Lead

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PERSONAL INFORMATION

Full Name

Date of Birth

Primary Language

Phone Number

Email Address

Full Address, City, State, Zip, Country

Do you have special needs in any of the following areas

Reading

Vision

Hearing

Mobility (e.g., wheelchair, wlaker, etc.)

Community (e.g., need for a translator)

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HOME

Marital Status

Single

Long-term Partner

Married

Civil Union

Divorced

Separated

Widowed

List your children with ages

List your current members of your household:

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EMPLOYMENT

Field label

Full-Time

Part-Time

At Home/Homemaker

Looking

Disabled

Retired

Student

Current occupation

Former occupation (if needed)

Employer

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ALLERGIES

List Medication Allergies And The Type Of Reaction You Had

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MEDICATIONS

List with doses. Include contraceptives, vitamins, supplements, etc. Attach list if needed.

Upload Medications (if need)

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YOUR MEDICAL CONDITIONS

(Check All That Apply)

Allergies

Anemia

Anxiety

Asthma

Blood Transfusion

Cancer

Clotting disorder

Congestive Heart failure

Depression

Diabetes mellitus

Emphysema/COPD

Gastroesophageal reflux disease (GERD)

Glaucoma

Heart murmur

HIV/AIDS

High Cholesterol

Hypertension/high blood pressure

Myocardial infarction

Nerve/muscle disease

Osteoporosis

Seizures

Sickle cell anemia

Substance abuse

Thyroid disease

Tuberculosis

Malaria/Typhoid

Kidney

Liver

Details/Other

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SURGICAL HISTORY

(Check All That Apply)

Appendectomy

Brain surgery

Breast surgery

CABG

Cholecystectomy

Colon surgery

Tonsillectomy

Appendectomy

Thyroid surgery

Lung surgery

C-section

Eye surgery

Fracture surgery

Hernia repair

Hysterectomy

Joint surgery

Bunionectomy

Varicose vein surgery

Prostate surgery

Weight reduction surgery

Small intestine surgery

Spine surgery

Tubal ligation

Valve replacement

Vasectomy

Vascular surgery

Cardiac stent Bladder surgery

Provide here if not listed

Have you ever had a blood transfusion?

If Yes, Please provide date

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FAMILY HISTORY

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(Check All That Apply)

Mother

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Father

Alcohol abu

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Sister

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Brother

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Daughter

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Son

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Other Relative

Alcohol abuse

Breast cancer

Ovarian cancer

Prostate cancer

Other cancer(s)

Diabetes

Heart disease

High cholesterol

Hypertension

Mental illness

Other Family History

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Habits and Activities

Do you use tobacco?

How much?

For how long?

Have you tried to quit?

In the past how many years ago did you quit?

Would you like to quit?

Do you drink alcohol?

If yes, how many times?

Do you or have you ever used recreational drugs?

If yes, please discribe.

Do you get regular exercise?

If yes, what kind of exercise?

How often

List any hobbies or leisure activities

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IMMUNIZATIONS (Vaccination)

Pneumonia (pneumovax)

Never

Never

Tetanus booster (Tdap)

Never

Never

TB skin test (PPD)

Never

Never

Hepatitis B vaccine

Never

Never

Hepatitis A vaccine

Never

Never

Varicella (chicken pox)

Never

Never

Shingles (Zostavax)

Never

Never

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PREVENTIVE CARE (Test or Procedure)

Colonoscopy

Never

Never

Bone density test (DXA)

Never

Never

Cholesterol test

Never

Never

PSA (prostate cancer test)

Never

Never

Pap smear

Never

Never

Mammogram

Never

Never

HIV test

Never

Never

List any abnormal screening test results (e.g. polyps, breast biopsies, etc.):

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SEXUAL HISTORY

Do you or have you ever used recreational drugs?

Have you had more than one sexual partner in the past year?

Have you ever had a sexually transmitted disease?

If yes, what and when?

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GYNECOLOGICAL AND OBSTETRIC HISTORY

How many times have you been pregnant?

Live births?

Miscarriages?

Abortions?

Do you use contraception?

If yes, what kind?

What was your age at first menses?

Menstrual periods:

Age at menopause?

Do you have hot flashes or other symptoms (specify)?

Any gynecological conditions or problems?

Name

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OTHER HEALTH ISSUES

Do you feel unsafe, or have you been harmed in a physical, emotional or sexual manner, in any relationship or recent encounter?

If yes, describe.

In the past year, have you had two weeks or more during which you felt sad, blue or depressed or when you have lost all interest or pleasure in things that you usually care about or enjoyed?

If yes, describe.

In the past year, have you had any major life changes or stresses that you feel have impacted your overall health?

If yes, describe.

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ADDITIONAL COMMENTS OR CONCERNS

Unique number. Change the text in the box to say “Type your last name in ALL CAPS and the numbers of your full date of birth.

Comments

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Certify by clicking the box on the left that the medication information provided is correct to the best of your knowledge. Any false information provided will count against your medical support. Your membership will begin after 60 days of submission of your form, this is to allow you to receive your membership card at the address provided. Each member is qualified for ₦‎200,000 in medical support within one calendar year.

Thank you message after form submission: Thank you for becoming an Afrimedical Support System member, please allow up to 60 days for your membership card to be mailed to the address provided.

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Afrimedical Support System

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CONTACT DETAILS

TrueSmart Care

Address: 2400 Augusta Drive, Suite 100, Houston, Texas 77057

Phone: (713) 791-4922

Email: drnoelle@truesmartcare.com

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BUSINESS HOURS

Monday: Closed
Tuesday: 9:00 am - 6:00 pm
Wednesday: 9:00 am - 6:00 pm
Thursday: 9:00 am - 6:00 pm
Friday: 9:00 am - 6:00 pm
Saturday: Closed
Sunday: Closed

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All Rights Reserved | TrueSmart Care PLLC

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