Medical History Form

Medical History Form
Full Name

First NameLast Name
Nail Service Request:
Pharmacy & Location (if applicable):
example@example.com
Have you been under care of a medical doctor during the last year?

YesNo
If yes, reason? Physician's Name
Are you taking taking an medication, drugs or pills, including regular dosages of aspirin?

YesNo
If yes, please list all within the last year, name and dosage:
Are you aware of having any allergic reaction to any medication or substance?

YesNo
If yes, please list:
Have you been a patient in the hospital during the last year?

YesNo
If yes, please describe:
Are you pregnant?

YesNo
If yes, how many months?
Have you ever had any unfavorable reaction to a nail service/treatment?

YesNo
If yes, please explain:
Check the conditions that apply to you:

AID/HIVAsthmaAlcoholismAllergies or HivesAnemiaArthristis, RheumatismArtificial JointsBleeding ProblemsBlood DiseaseBruise EasilyCancerChemotherapyChest PainChronic CoughCold Sores, Fever BlistersCongenital Heart DiseaseContact LensesCortisone MedicineDiabetesEmphysemaEpilepsy or SeizuresFainting or Dizzy SpellsGlaucomaHay FeverHeadacheHeart Attack, SurgeryHeart MurmurHemophiliaHepatitis A or BHigh Blood PressureKidney DiseaseLatex AllergiesLiver DiseaseLow Blood PressureNervous DisordersNeurological DisordersOsteoporosisPacemakerPenicillin AllergiesPsychiatric CareRadiation TherapyRheumatic FeverSickle Cell DiseaseSinus TroubleSmokingStomach UlcerStokeSwollen AnklesThyroid ProblemsTMJ ProblemsTuberculosisTumorsUlcersVenereal DiseaseYellow JaudiceOther
If you have or had any disease, condition or problem not listed, please list:
I understand the above information is necessary to provide me with nail and foot care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify my nail technician of any changes in my health or medication.
Client Signature

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Date

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Date
Nail Technician Signature

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Date

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Date
Should be Empty: