medspa

CONSULTATION PROCESS

PATIENT MEDICAL HISTORY FORM

 Male    Female



Please Complete the Following

1 Do you have any health problem.? if yes, please described   Yes   No
2 Have you had any major surgery.? if yes, please described   Yes   No
3 Have you had any cosmetic surgery.? if yes, please described   Yes  No
4 Do you take any medication/nutritional supllements/herbal medications.? if yes, please described  Yes  No
5 Have you ever had any adverse reaction to local or general Anesthesia   Yes   No
6 Do you take aspirin/Blood Thinnerss   Yes   No
7 Have You Had any allergic Reaction to medicine.?if yes, What type and what year   Yes   No
8 Do you have any allergy.? if yes, please described  Yes   No
9 Do you Smoke.? if yes, how much  Yes   No
10 Do you take Alcohal or other reaction medicines/drugs.? if yes, how much   Yes   No
11 Are you Pregnant/Lactating  Yes  No
12 Do you have any children.?if yes, how many and how old is the youngest  Yes   No

The following question concern you and your family. please fill yourself and/or state which family member has the Problem

1 Neurological   Yes   No
2 Diabetes   Yes   No
3 Heart Problem   Yes   No
4 Breathing/Lung Problem   Yes   No
5 Gastrointestinal Problem   Yes   No
6 Kidney Problem  Yes  No
7 Do you have any skin problem/skin cancer  Yes  No
8 Other medical Problem including communicable diseases  Yes   No

I understand that all the information furnished above is accurate and true.
I consent to treatement/management strategies as discussed with doctor and bear
financial responsibility for the same.