Health History

  • Contact Information

  • Biographical Information

  • Please enter a value between 0 and 20.
  • Primary Care Physician

  • Health and Wellbeing Questionare

  • Hypothyroid Symptoms

  • Medical History

  • Medication/Drug Consumption

  • Lifestyle

  • Please enter a value between 0 and 10.
  • Please enter a value between 0 and 10.
  • Please enter a value between 0 and 10.
  • Please enter a value between 0 and 10.
  • Please enter a value between 0 and 10.
  • Please enter a value between 0 and 50.
  • Please enter a value between 0 and 10.
  • Supplement Usage

  • Hormone Usage

  • Liability Waiver

    By signing this form below, I agree to and understand the following statements.
    • I understand New Era does not practice medicine. I understand that New Era is a management service organization that received my request for a physician consultation and, in turn, a Illinois Licensed physician will review and response.The physician who reviews my medical history and who makes the medical determination as to whether or not I receive the medication.
    • I understand New Era does not direct,control or influence the treatment decisions made by the Consulting Illinois Licensed Physician with respect to my care and/or my request from New Era is not liable for any negligent act or omission of the Consulting IL licensed Physician. I understand that my medical records become sole property of the Consulting Illinois Licensed Physician and copies may be made available to New Era.
    • I am soliciting this site to determine whether or not I fit the criteria for certain prescription medications. I am not currently seeing my regular primary care physician at this time because: A) this site is more convenient. b) for other personal reasons.
    • The IL. Licensed Physician" reviewing my "Medical History" will make a decision based upon my honest responses in making his or her decision regarding my request. I understand each question I answered on the questionnaire. I responded to truthfully, accurately and completely.
    • Before taking any medication prescribed, I will ensure that I have completed the following: Accurately and honestly completed a comprehensive physical examination by an IL. Licensed physician. I received a copy of the written report of said examination and that I have identified my responses to the "Medical History" any findings from my physical examination that are not within the accepted average range.
    • In accordance with the United States Arbitration Act, I agree that any dispute arising out of or related to, the provision of services by the "Consulting IL. Licensed Physician", by New Era, its affiliates, or their employees, partners and agents, shall be subject to final and binding arbitration exclusively through the procedures of the American Arbitration Association.