EWI Health History Form

If you have already completed a Health History form please login. If this is your first visit, please complete the form below to setup an account. After you complete the Health History form you will be able to submit it electronically to the EWI staff and print a copy of your Medical History for your records.

Account Profile

2. First Name: *
3. Last Name: *
4. Date of Birth: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 *
5. Gender: Male Female *
6. E-mail: *
7. Phone: *
8. Address: *
9. Address 2:
10. City: *
11. State: *
12. Zip/Postal Code: * (If none, enter N/A)

Account Setup

1. Please choose a username and password that you will use to login to your account in the future.
2. Username: *
3. Create Password: *
4. Re-type Password: *
5. Terms of Use: Eisenhower Medical Center Executive Physical Program Patient Terms and Conditions This Eisenhower Medical Center ("EMC") Executive Physical Program Services ("Program") Patient Terms and Conditions ("Agreement") sets forth the terms under which individuals ("Patients") shall participate in the EMC Program. 1. EMC Program The EMC Program provides services specified in Attachment I attached hereto (the "Program Services"). The Program Services include only services not covered by insurance since these services are screening in nature. The entire fee described herein is in payment for services not covered by medical insurance under which Patient is covered or by Medicare. The Program Services do not include any healthcare or medical services, testing or other services not specifically listed as one of the Program Services in the Agreement, including any Attachments hereto. 2. Fee Patients will pay a fee (the "Fee") to EMC Program Services for the EMC Program Services. The fee is set forth on attachment II which is attached hereto and fully incorporated herein. 3. Consent Form Patient acknowledges and agrees that Patient will be required to execute a consent form regarding consent to provide program services and the release of information for compliance purposes provided by EMC Program physician prior to receiving program services. 4. Change of Law If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party"s rights, obligations of operations associated with the Agreement, then the agreement may be terminated. 5. Limitation of Liability EMC Program"s liability to Patient arising out of or related to the Agreement, including providing the EMC Program Services thereunder, shall be limited to the Fees paid by Patient preceding the date on which the claim arises. In no event shall EMC Program be liable for any indirect, consequential, special or punitive damages of any kind, whether arising in contract, tort, strict liability or otherwise, even if EMC Program has been apprised of the possibility of such damages. 6. Health Care Decisions EMC Program is not a health care provider, does not practice medicine and shall not interfere in any manner with the relationship between EMC Program physician and a Patient with regard to medical treatment. Patient acknowledges and agrees that Patient and Patient"s EMC Program physician are solely responsible for any medical decisions regarding the course of treatment for any illness or condition of Patient. If Patient is unsure of the efficacy or appropriateness of any treatment plan proposed by Patient"s EMC Program physician, it is the responsibility of Patient to seek additional medical guidance. Patient further acknowledges and agrees that to the extent that Patient"s service level includes personalized medical research or disease management services form EMC Program, Patient is ultimately responsible, together with such professional and other advisors as Patient shall select including Patient"s EMC Program physician, for evaluating any information, advice or guidance provided by EMC Program, and EMC Program hereby disclaims any and all warranties of any kind with regard to such personalized medical research and disease management services, express or implied, including the implied warranties of fitness for a particular purpose or merchantability. 7. Miscellaneous The Agreement and any other materials attached to or incorporated into the Agreement by reference (a) shall be governed by California law applicable to dealings in such state by residents of such state and without regard to California"s rules regarding conflicts of laws, (b) sets forth the entire agreement and understanding between Patient and EMC Program with respect to the subject matter hereof, and has priority over all other documents, verbal consents and/or understandings related thereto, (c) may not be modified except in a written document signed by Patient and EMC Program, and (d) may not be assigned by Patient. Any communication required or permitted to be sent under the Agreement shall be in writing and sent via facsimile, certified mail return receipt requested, or via overnight courier to the other party at their last known address. Either party may change the address to which communications to such party shall be addressed by notice given to the other party in the manner specified above. Headings in the Agreement are included herein for ease of reference only and have no legal effect. No party shall be liable for failure of or delay in performing obligations set forth in the Agreement, and no party shall be deemed in breach of its obligations, to the extent such failure or delay is due to natural disaster, Act of God or any other cause reasonably beyond the control of such party. Any waiver by either party of any rights arising from any breach of any terms of the Agreement shall not be construed as a continuing waiver of other breaches of the same or other terms of the Agreement by the other party. Should any clause, term or provision of the Agreement be held by a court of competent jurisdiction to be illegal, invalid, unenforceable or in conflict with any law, the legality, validity and enforceability of the remaining clauses, terms and provisions shall not be affected or impaired thereby. Any dispute between Patient and EMC Program arising under the Agreement which the parties are unable to resolve through negotiation shall be resolved exclusively by arbitration before a neutral arbitrator in Riverside County, California under the auspices of the American Arbitration Association, in accordance with its then current rules and procedures for commercial arbitration. Any award rendered pursuant to such arbitration shall be final and binding upon the parties, and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Each party shall bear its own attorneys" fees, costs and expenses in connection with any such arbitration. The Agreement shall be binding upon and inure to the benefit of the respective parties and their respective permitted heirs, successors and assigns. The Agreement may be executed in any number of counterparts, and by the parties on separate counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. ATTACHMENT I Executive Physical Program Services Services include: 1. A comprehensive review of your medical history and complete medical exam and a lifestyle assessment providing meaningful recommendation for maximizing your health. 2. Preventive Screening Tests: a. Vascular Screening b. Comprehensive blood testing c. Physiologic and anatomic tests d. Vision, hearing, breathing exams e. Musculoskeletal fitness assessment f. Ultrasound Screen (Includes carotid and aortic artery) 3. Board Certified physician consultation to discuss test results, diagnostic impression and recommendations 4. A comprehensive report of your results within seven days. ATTACHMENT II Executive Physical Fee Fee: The fee for the Executive Physical Program shall be $1,500.00. Payment: Payment for services must be made prior to participating in the Executive Physical Program. If after payment and prior to obtaining any diagnostic testing, the Executive Physical is not completed by the patient, a cancellation fee of $100.00 shall be applied and the remaining charge will be refunded. For Credit card payments the card will be credited, for cash paying patients, the overall fee for the Executive Physical shall be refunded less a 100.00 cancellation fee. If the patient does not complete the Executive Physical after obtaining any services, including diagnostic blood work, there will be no refund of the fee for the Executive Physical program. If the cancellation is due to the action of EMC, the entire charge for the Executive Physical shall be refunded.
   Printable Copy
6. Agreement:
   I agree to the Terms of Use above.*