Transformations Medical History Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Marital Status* This field is required.
Single
Divorced
Married
Widowed
4
Sex* This field is required.
Male
Female
5
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Email* This field is required.
example@example.com
8
Emergency Info* This field is required.
Emergency Contact
Relationship
Emergency Contact Phone
9
Referred By* This field is required.Check all that apply
Patient
Public Seminar
Physician
Advertisement
Internet Website
10
Name of Referrer* This field is required.
11
Interest/Concern* This field is required.Check all that apply
Aging Face (Non-Surgical)
Injectable Fillers
Forehead Lift (Non-Surgical)
Skincare Services/Products
Botox/Dysport
Laser Services
Vascu Treatment
Cryo Treatment
Educational Programs/Events
12
Care Providers* This field is required.
Primary Care Physician
Dermatologist/Estetician
13
Have "YOU" Had Any Problems with the Following Conditions* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Heart Disease
High Blood Pressure
Diabetes
Stroke
Excessive Bleeding
Excessive Bruising
Poor Healing
Excessive Scarring
Cancer
Skin Cancer
Glaucoma
Heart Disease
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 11
14
Please Explain any "YES" Answers Here
Huge
Large
Normal
Small
Ok
Ok
15
Have Any "RELATIVES" Experienced Problems with the Following Conditions* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Heart Disease
High Blood Pressure
Diabetes
Stroke
Excessive Bleeding
Excessive Bruising
Poor Healing
Excessive Scarring
Cancer
Skin Cancer
Glaucoma
Heart Disease
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 11
16
Please Explain Any "YES" Answers Here
Huge
Large
Normal
Small
Ok
Ok
17
Medical History* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Do you have a history of sunburns in childhood?
Do you have a heart murmur?
Do you have any artificial joints?
Do you have chest pain or pressure?
Do you have high cholesterol?
Do you have asthma or lung problems?
Do you have seasonal or environmental allergies?
Do you have any thyroid problems?
Do you have liver problems?
Have your ever had hepatitis? Type A , B, or C?
Have you ever had a seizure or convulsions?
Do you have problems with your eyes (besides glasses)?
Is any part of your body paralyzed or numb?
Do you have any kidney problems?
Do you have anemia or any problems with your blood?
Have you ever had a blood transfusion?
Have you ever had cold sores, or fever blisters?
Do you have a history of dry eyes?
Do you have a history of sunburns in childhood?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 18
18
Women Only* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
Do you have an IUD?
Are you, or could you be pregnant?
Are you breast feeding?
Do you wear hearing aids?
Have you been diagnosed with MRSA?
Do you have an IUD?
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 5
19
Please List Any Other Problems That Have Not Been Covered
Huge
Large
Normal
Small
Ok
Ok
20
Please List All Past Surgeries/Operations
Huge
Large
Normal
Small
Ok
Ok
21
Medications* This field is required.
Yes
No
Do you take any medications, including birth control pills or aspirin?
If "Yes" Please List. If "No" enter N/A.
Yes
No
Are you allergic to any medications?
If "Yes" medication/reaction?. If "No" enter N/A.
22
Vitamins* This field is required.
Yes
No
Do you take vitamins, over the counter medications, or herbal supplements?
Please List. If no, enter N/A.
23
Other Questions* This field is required.
YesNo
YesNo
YesNo
YesNo
Have you taken steroid medication in the last year?
Have you ever taken the medication Accutane?
Do you have a sensitivity/allergy to latex?
Do you have a sensitivity/allergy to tape?
Have you taken steroid medication in the last year?
YesNo
YesNo
YesNo
YesNo
1 of 4
24
Drugs & Alcohol* This field is required.
Yes
No
Do you smoke
If so, how much? If not, enter N/A.
Yes
No
Do you drink alcohol?
If so, how much? If not, enter N/A.
Yes
No
Do you use recreational drugs?
If so, how much? If not, enter N/A.
25
Consent for Release of Information/Assignment of Benefits* This field is required.
26
Release Signature* This field is required.
Clear
27
Consent for Release and Use of Photographs and or Video* This field is required.In connection with the medical services I am receiving from Transformations Medical Spa, I consent that photographs and/or videos may be taken of me, or parts of my body under the following conditions: The photographs and/or videos may be taken only with the consent of my medical provider, and under such conditions, and at such time as may be approved by her. The photographs and/or videos shall be taken by my medical provider or by a photographer approved by her. My photographs may be utilized by Transformations Medical Spa in the following manner, as long as my identity is not made known: - Medical records (patient charts) - Medical research, education or science - In professional journals, professional videos, or medical books - On social media tools that include but do not limit to the Transformations website and Facebook page
YESNO
28
Media Signature* This field is required.The undersigned acknowledges that he/she relinquishes all right, title, and interest in these photographs and or videotapes, or any right to profit or gain directly or indirectly realized through the use of the photographs and / or videos.
Clear
29
Thank you for taking the time to fill out this form. You will get a confirmation email and we will get back to you as soon as possible.
30
Please verify that you are human* This field is required.
31
Tags
Todo
In Progress
Done
Should be Empty: