Weight Loss Medical History Intake Form

Medical History Intake Form

Please complete all sections to help us provide the best possible care.
Dr. Juan S. Blanch Jr. MD

Medical director for Carmen And Santos Med Spa
Patient Information

Please provide your personal information.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Month-Day-Year
Age
Sex*

FemaleMale
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Physical Measurements

Please provide your most recent measurements.
Height
Feet*
3-7
Inches*
0-11
Weight (lbs)*
Current weight in pounds (lbs)
BMI
Systolic Blood Pressure*
For example 120
Diastolic Blood Pressure*
For example 80
Ideal Weight*
In Pounds (lbs)
Medications

Please provide your current medications
Current Medications (select all that apply)*

Blood PressureTransplantAspirinAntidepressantInsulinStimulants (Vyvanse, Adderal)Diabetes OralSteroids (Prednisone in last 3 months)Blood Thinner (Coumadin, Eliquis, Pradaxa, Xarelto)Accutane (last 12 months) or other RX acne medicationsRetin A, retinol containing substancesI am not on antibacterial medication to treat bacterial infections.None of theseOther
List any other medications you are currently taking:
Do you have any Allergies?*

YesNo
If yes, please list allergies.
Medical History Review

Please answer the following questions.
Are you currently pregnant, lactating or breastfeeding?*

YesNoNot applicable
Physician's Name if pregnant.
WARNING: If planning on getting pregnant, you must wait 3-4 months to allow the medication to empty out of your system before getting pregnant.
Please indicate if you have or have ever had any of the following conditions (select all that apply):*

Myasthenia GravisHepatitisHerpes/ShinglesEye DiseaseAutoimmune DiseaseEaton Lambert DisorderPersistent NumbnessFocusing Vision ProblemsPersistent Muscle WeaknessEasy BleedingFacial SurgeryFacial FillersMultiple SclerosisAmyotrophic Lateral Sclerosis (ALS)History of MRSAHeart Rhythm DisorderTake antibiotics for dental proceduresDiabetesCancer in treatmentHistory of Chemotherapy or Radiation TherapyDifficult Numbing with Dental WorkKeloid FormationNone of the above
Have you been in a hospital or had an operation in the last 2 years?*

YesNo
If yes, please provide details:
Do you have thyroid nodules?*

YesNo
Do you have a family history of medullary thyroid carcinoma or multiple endocrine neoplasia?*

YesNo
Consent and Acknowledgment

Please read and sign below.
Client Signature*

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Date Submitted*

MonthDayYear
Date
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Medical History Intake Form

Dr. Juan S. Blanch Jr. MD

Patient Information

Physical Measurements

Height

Medications

Medical History Review

Consent and Acknowledgment