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    BarnMD Membership Form

    BarnMD Membership Registration

    Valid for One Year from Date of Registration

    www.BarnMD.org [email protected]
    Complete this form to register or renew your BarnMD membership
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    Member Details

    e.g., AA, AS, SS

    e.g., A+, O-

    Format: +234XXXXXXXXXX

    [email protected]

    e.g., 175

    e.g., 70

    Emergency Contact

    Format: +234XXXXXXXXXX

    Teleconsultation Preferences

    e.g., Weekdays 9 AM - 5 PM

    e.g., English, Yoruba

    e.g., Doctolib, KRY

    Medical History

    List any past surgeries and dates

    List reasons and dates of previous hospitalizations

    Present Health Concerns

    e.g., 3 days ago, childhood

    e.g., stress, certain foods

    Current Medications

    e.g., 5mg, 1 tab

    e.g., BID, once daily

    Allergies

    List any known drug allergies

    List any known food allergies

    List any known environmental allergies

    Family Medical History

    e.g., Cancer, Heart Disease

    Lifestyle Information

    e.g., 3 times a week, daily walk

    e.g., Vegetarian, Balanced, High sugar

    Gynaecological History (For Females Only)

    e.g., Regular, Irregular

    e.g., 5 days

    e.g., 3 per day

    e.g., Mild, Severe

    Obstetric History (For Females Only)

    Total pregnancies

    Live births after 20 wks

    Full-term births

    Preterm births

    Miscarriages/abortions

    Living children

    Paediatric Section (Complete if Member is Under 18)

    e.g., 3.5

    e.g., 40

    e.g., Vaginal, C-section

    Any complications at birth?

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