Medical History Form Content for the medical history form NameSS#Date AddressCityStateZip CodeEmail Phone (Home)Date of birth Company / OccupationInsurance CarrierCurrent MedicationsIt is required by the state of Tennessee that all patients be looked up on the database. Please list all current medications you are presently taking or have had filled by a pharmacy in the last 30 days. Medical History Headache Lactose Intolerance Depression Shortness of Breath Gallbladder disease Gout Heart Palpitations Prostate Disease Scarlet Fever Heart Murmur Bowel Irregularity Chronic Rashes Chest Pain Incontinence Rheumatic Fever Dizziness/ Fainting Sexual Dysfunction Mumps Vascular Disease Venereal Disease Measles Allergies/ Hay Fever Frequent Infections Rubella Asthma Hepatitis Polio Bronchitis Anemia Diphtheria Pneumonia Arthritis Tetanus Ulcer Osteoporosis GI Disorders Nervousness Drug Other Drug Allergies:WeightHeightLast Pap SmearWomen Only: Pregnant?Please selectYesNoPlanning PregnancyPlease selectYesNoLast PeriodLast MamogramHabits SmokePlease selectYesNoPacks dailyAlcoholPlease selectYesNoAmountCaffeinePlease selectYesNoHow much?Exercise RoutineWhat is your Diet like nowRelease of Liability: By providing my signature below, I certify that the medical information I provided on this form is true to the best of my knowledge. I am not pregnant or breastfeeding at this time, and should I become pregnant, I will immediately stop this medication and inform my healthcare provider of my condition. I am aware that the provider here is not my personal medical provider and is generally not on-call for emergency purposes. Furthermore, I acknowledge that in the last 6 months I have received blood tests that include GBC, Glucose level, Thyroid panel, Lipid panel, Potassium level, and Renal function test. I am not aware of any abnormalities on any of these tests and I have not been instructed by my Primary Care Provider or any other medical specialist to refrain from a weight loss medication. I give my full consent for this clinic from any liability and its providers and employees from any and all injuries and losses that I may sustain as a result of any misrepresentation that I made in my medical history and/or physical exam. In addition, my consent allows my blood to drawn and tested for but not limited to HIV and Hepatitis, in the event of a needle stick. I understand that this release of liability is ongoing until such time that I make necessary corrections. Newsletter? Check here if you do not want to receive to receive emails from Complete Aesthetics with Coupons, Specials and New Product Notices. SignatureDate This iframe contains the logic required to handle Ajax powered Gravity Forms.