VENUS VERSA MEDICAL HISTORY

Client Name:*

First NameLast 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

CityState / Province

Postal / Zip CodeCountry

Home Phone:*

Area CodePhone Number

Work Phone:

Area CodePhone Number

Cell Phone:*

Area CodePhone Number

Email:*

example@example.com

Can I leave a message at:*

HomeWorkCellEmail

Health Card No. (& Version Code):

If applicable

Emergency Contact Name:*

First NameLast Name

Emergency Contact Number:*

Area CodePhone 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