Past Medical History & Intake

Today's Date *

Full Name *

Phone *

Email *

Date of birth *

Gender *

Address *

City *

State *

Emergency Contact - Full Name *

Emergency Contact - Phone Number *

Emergency Contact - Address

Reason For Visit - Please briefly describe what services you're interested in receiving today *

What (if any) previous surgeries have you undergone?

General Surgery *

Plastic Surgery *

Surgeries (Other)

Allergies (Medications, Food, etc.) *

Current Medications: (Please include over the counter & supplements) *

Please check any conditions that apply to you:

Conditions - Hematology *

Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)

MTHFR

G6PD Deficiency

None

Please check any conditions that apply to you:

Conditions - Psychological *

Anxiety or Panic Attacks

Depression

Suicidal Ideations

None

Please check any conditions that apply to you:

Conditions - Cancer *

Chemotherapy

Radiation

None

Location of Cancer

Please check any conditions that apply to you:

Conditions - Pain *

CRPS

Fibromyalgia

Other

None

For females only (men skip to the next question)

Last Menstrual Period

Any chance that you are pregnant?

Are you currently breastfeeding?

Do you drink alcohol or abuse any types of drugs? If so, please explain: *

Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.? *

Would you like to tell us anything else that you feel like is important? *

I attest that the information I have provided is true and accurate to the best of my knowledge:

Patient Medical History & Intake Form Signature *

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