Medical History FormMedical History Form Name* First Last Date of Birth* Home PhoneCel PhoneEmail* Emergency Contact First Last Emergency PhoneAgeHeighteg. 5'4"WeightOccupationPlease check off all of the following medical conditions you now have or have had in the past, if you have had none, please check “None of the above”* bleeding tendency diabetes blood transfusions glaucoma dry eyes lung disease TB asthma or wheezing emphysema bronchitis irregular heart beat chest pain heart disease high blood pressure pace maker heart attack stroke epilepsy heart burn intestinal ulcers or bleeding rheumatoid arthritis scleroderma lupus porphyria depression mental illness drug or alcohol addiction hepatitis B hepatitis C HIV contact lenses loose or chipped teeth dentures dental implants veneers caps none of the aboveAny other serious illness or injury please explain belowPlease list all medications that you are currently taking or have used in the past 6 months.There exists a risk if our staff is not aware of the general health and medical background of a client. This information may critically affect what procedure we may recommend or safely undertake. Please provide us with the following information and keep it updated.Please list all Naturopathic, Health Food Supplements and Vitamins:Please list all ALLERGIES including LATEXAre you a smoker?* Yes NoIf you are an ex-smoker, for how long are you smoke free?How much are (were) you smoking?For how long?How much alcohol do you drink per week?Caffeine per week?Is there any possibility that you may be pregnant at this time?* Yes NoDo you have a history of cold sores?* Yes NoWhen was your last outbreak?Do you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma or skin cancer?* Yes NoIf yes, please indicate which and explainPlease list all surgeries that you have had (include plastic surgery and wisdom teeth removal) with the date you had the surgeryHave you or anyone in your family ever had or have a history of unusual reactions or problems with LOCAL anesthesia (dental freezing), TOPICAL anesthesia (anesthetic creams or gels) or GENERAL anesthesia (rashes, muscle weakness, jaundice, breathing problems or unexpected fevers(s)? Yes NoPlease explainHave you ever seen a cardiologist?* Yes NoWhat is your Physician's NameDate of last EKG? * I acknowledge that I have disclosed my complete medical history and the above is a complete and accurate representation of my medical and psychological status. I represent to the physicians and staff that I am at least 18 (eighteen) years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize a history examination by my doctor and such assistant or staff as may be assigned by him/her.If appropriate, I authorize the release of any medical information for the purpose of processing insurance claims on my behalf. I authorize payments of medical benefits directly to the doctor for services provided to me. A copy of this authorization shall be considered as valid as the original. I understand that photography is a necessary part of planning and evaluating cosmetic procedures. I authorize the taking of photographs at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs will be used solely for documentation purposes and will be kept confidential unless otherwise disclosed.I understand that there is a consultation fee for the initial visit which is due at the time of my appointment unless other arrangements have been made in advance.Signature*Date* Location*LocationPitt MeadowsPort Moody
