Patient Evaluation Medical Form

Sales Person

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Language

The best time to contact you?

At a specific time

Address

Street Address

Street Address Line 2

CityState

Zip Code

DOB

Ex. MM/DD/YYYY

Age

Gender

Marital Status

Height (Feet)

Height (Inches)

Weight in Pounds

BMI

What procedure are you interest in?

Previous Surgeries?

Allergies

Other Allergies please list

Are you in good health?

Are you under medical treatment now?

If yes, which treatments:

Have you ever been hospitalized for any surgical operation or serious illness within thelast 5 years?

If yes, please explain:

Have you ever had any complication after undergoing general anesthesia in the past?

If yes, please explain

Are you taking any medications including non- prescription medicine?

If yes, please which medications are they:

Are you under any type of pain management?

If yes, please which medications are they:

Have you ever taken or are currently taking any weight loss medication?

Do you use tobacco/nicotine products?

Are you exposed to second hand smoking?

How often do you consume alcohol?

Do you use or do you have history of using recreational drugs?

Number Of Children

When was your last delivery

Are you pregnant or think you may be pregnant?

Are you nursing?

If no, when was the last time you breastfeed (month/year)

Are you under any type of birth control treatment? ( Oral contraceptives, Nuva ring, IUD, Arm implant, Depo shot, etc.)

Have you had any abortion/miscarriage or pregnancy in the last 8 weeks?

Have you had or do you have any of the following conditions?

Have you ever had any operations to your head, eyes, ears or spine?

Do you have any surgical hardware or material placed in any part of your body?

Any Medical conditions we should be aware of?

Have you had abnormal bleeding?

Have you had any foreign substance injected in your buttocks area?

Pre-Qualification

Patient Evaluation Medical Form

Health History

Women only