Medical History "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Patient InformationFirst Name*Last Name*Email* Date of Birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical History* None Anxiety Blood Clots Hepatitis C Hypertension Pregnant or Nursing Myocardial Infarction Seizure Disorder Thyroid Disease Other Exercise Activity* Moderate Vigorous Sedentary Check current patient problems*Tobacco Use* No Daily Weekly Less Former User Alcohol Use* No Daily Weekly Less Former User Are you currently taking supplements or prescription medication?* Yes, I am. I do not take any medications. Are you allergic to any medications?* No Yes. Please list Other: List any medication*list any medications **Are you allergic to any medications? *Have you had any surgeries in the past 5 years?* Yes No Other Previous Surgical History* None Gastric Bypass Bilateral Tubal Ligation Hysterectomy TAH/BSO Others: Have you had any surgeries in the past 5 years?*Previous Surgical History*Medications due to allergies* Yes No Other Are you currently on any mood altering or anti-depression medication?* Yes No Medications due to allergies*Are you currently pregnant, nursing or trying to get pregnant?* Yes No Signature of Patient/Responsible PartyDate MM slash DD slash YYYY FileMax. file size: 1 MB. Δ Stay Inspired: Follow Us on Instagram evexiamedspa
