RelaxCT- Medical History
The purpose of this form is to assure your safety and best possible service. We adhere to all HIPPA guidelines and assure your information is kept strictly confidential.
Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Gender?
*
Male
Female
DOB
-
Month
-
Day
Year
Date
Phone Number
*
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Check the symptoms that you're currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Musculoskeletal
None
Please list any medications you are currently taking including over the counter.
Do you use or do you have history of using tobacco?
Please Select
Yes
No
Please type your full name. By doing so you confirm you are above the age of 18 years old and are providing this information on behalf of yourself as a potential client of RelaxCT
Signature
Submit
Should be Empty: