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Vascular Surgery Patient Health Questionnaire Mobile App

The Vascular Surgery Patient Health Questionnaire mobile app makes it easy for patients to complete a medical questionnaire for vascular surgery using a mobile device. The app covers: patient information, referring physicians, primary care physicians, reasons for visit, previous surgeries, previous hospitalizations, dialysis, stress test, medical history, family history, medications and allergies and review of systems. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Vascular Surgery Patient Health Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    PLEASE COMPLETE ALL PAGES AND BRING FORM WITH YOU TO CLINIC

  • Ico textbox

    Name:

  • Ico date

    Date of Visit:

  • Ico date

    Date of Birth:

  • Ico textbox

    Registration #:

  • Ico textbox

    Home Phone:

  • Ico textbox

    Cell Phone:

  • Ico textbox

    Work Phone:

  • Ico textbox

    Email Address:

  • Ico textbox

    Place of Work:

  • Ico dropdown

    Can we send you an email?

  • Ico textbox

    Emergency Contact:

  • Ico textbox

    Emergency Phone:

  • Ico textbox

    Contact Relationship:

  • Ico dropdown

    Does this person live with you?

  • Ico checkbox

    Primary Care

  • Ico checkbox

    Specialist

  • Ico textbox

    What Type:

  • Ico textbox

    Name of Referring Physician:

  • Ico multiline

    Address:

  • Ico textbox

    Office Phone:

  • Ico textbox

    Office Fax:

  • Ico statictext

    IF REFERRING PHYSICIAN IS NOT PRIMARY CARE, PLEASE PROVIDE INFORMATION

  • Ico textbox

    Name of Primary Care Physician:

  • Ico multiline

    Address:

  • Ico textbox

    Office Phone:

  • Ico textbox

    Office Fax:

  • Ico multiline

    REASON FOR VISIT:

  • ...and More!

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