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(713) 330-8300

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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Phone number

Last Name

Date of Birth

Are you a new patient to WellAid Clinic? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

Current Medication

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat, nausea, headache, vomitting, loss of taste or smell

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Location

Services

Open

Monday - Friday

9:00 am - 3:00 pm

Saturday

8:00 am - 11:00 am

Sunday

Closed

1520 Holland Ave.

Houston, TX 77029

(713) 330-8300

Beauty & Aesthetics

Family Wellness

Affordable Healthcare Plans

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