Anti-Aging/Future Medicine
Form

General
First Name:
(Nombre) 
Last Name:
(Nombre) 
Date:
(Fecha)
Age:
(Edad)
Address:
(Direccion)
City:
(Ciudad)
State:
(Estado)
Zip Code:
(Codigo Postal)
Phone Home:
(Telefono)
Marital Status:
(Estado Civil)
Sex:
(Sexo)
Date of Birth:
(Fecha de Nacimiento)
Employer:
(Lugar de Empleo)
Occupation:
(Ocupation)
Emergency Contact:
(Contacto de Emergencia)
Relationship:
(Parentesco )
Emergency Phone Home:
(Telefono Emergencia de Casa)
Emergency Phone Work:
(Telefono Emergencia de Trabajo)
Email Address: (You will be subscribed to our monthly newsletter, you may unsubscribe at any time.)
How did you
hear about us?
TV:


What Channel?
Radio:


What Station?
OtherSources:


Internet Sites:
Referred by:


Newspaper / Flyer / Magazine:


Health History
Medications:
Allergies:
Current Medical Diagnosis:
Current/Past Medical or Surgical Problems::
Surgeries
/Dates:
Have a history of?
Heart Disease Mental Disease Neuro-muscular Disease
Excessive Bleeding Auto-immune Disorders Diabetes
High Blood Pressure Liver Disease Cold Sores/Fever Blisters
Other    
Please explain:
Current Medical History:
Ear Infections Dizzy Spells Drug Abuse
Nose Bleeds Hypertension Hemmorrhoids
Loss of Hearing Heart Murmur Frequent Urination
Bad Vision Palpitations Hernia
Glaucoma Sinus Trouble Gall Bladder
Ringing in Ears Swollen Ankels Kidney Disease
Irregular Pulse Fainting Spells Sudden Weight Loss
Sore Throat Chest Pain Fatigue
Allergies Headaches Anemia
Hoarseness Stroke Cancer
Pneumonia Indigestion Diabetes
Bronchitis Stomach Ulcers Loss of Appetite
Asthma Diarrhea Convulsions
Short of Breath Alcohol Abuse Mumps or Measles
Thyroid Disease Joint Pain Numb Arm/Leg
Back Pain Nervousness Bloody/Tarry Stool
Rashes Depression Chicken Pox
Insomnia Moodiness Broken Bones
Memory Loss Phobias Polio
Constipation Mental Illness Tuberculosis
Other    
Please explain:
Are you?
Pregnant:

Yes No

Nursing: Yes No
Do you?
Smoke:

Yes No

Drink Alcohol: Yes No Amount per day:

Post Treatment Instructions

The above information is true and accurate to the best of my knowledge.

Patient Signature: Date:
Witness Signature: Date: