VENUS VERSA MEDICAL HISTORY

Client Name: *

First Name Last Name

Date of Birth (mm/dd/yy): *

Ex. 11/07/1970

Height: *

Ex. 5 feet 5 inches

Weight: *

Ex. 135

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone: *

Area Code Phone Number

Work Phone:

Area Code Phone Number

Cell Phone: *

Area Code Phone Number

Email: *

example@example.com

Can I leave a message at: *

Home Work Cell Email

Health Card No. (& Version Code):

If applicable

Emergency Contact Name: *

First Name Last Name

Emergency Contact Number: *

Area Code Phone Number

Referred By:

If applicable

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 check 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”. *

Any other serious illness or injury (please explain):

If applicable

Please list all medications that you are currently taking or have used in the past 6 months. List name of medication, amount and frequency. *

Ex. Eletriptan, 40 mg, as needed

Please list all naturopathic, health food supplements, and vitamins: *

Ex. vitamin D, pre-natal vitamin