General New Patient Form - Fusion Medical Aesthetics

Date*

Name*

First MI Last

Phone*

Birthdate*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact*

Relationship*

Phone Number*

Medical History (check all that apply):

High Blood Pressure
Heart Disease
Asthma
Diabetes
Thyroid Problems
Oesteoporosis
Abnormal Pap
Other

If other, please list:

Please list any prescriptions, over the counter medications, vitamins, and supplements

Have you had any surgeries?*

No
Yes

If yes, then please list year(s) & surgeries below:

Are you allergic to any medications?*

No
Yes

If yes:

Do you use tobacco products?*

Never
Quit
Yes, currently

Type

Number of days per week

Number of years

Please enter a number less than or equal to 100.

Do you drink alcohol?*

No
Yes

If yes, how often?

Other drug use?*

Never
Quit
Yes

General (check all that apply):

Weight change
Fever
Change in appetite
Fatigue
Shaking chills
Night sweats
Weakness

Heart (check all that apply):

Chest pain
Irregular heartbeat
Rapid heartbeat
Swelling in legs

Urinary (check all that apply):

Frequent urination
Leaky bladder

Hormones (check all that apply):

Heat or cold intolerance
Loss of libido
Vaginal dryness
Vaginal laxity
Excessive hunger
Erectile problems

Psychological (check all that apply):

Depression
Anxiety
Drug abuse
Alcohol abuse
Difficulty concentrating
Difficulty sleeping
Loss of interest in activities usually enjoyed

Muscle, Joints, and Bones (check all that apply):

Joint stiffness or pain
Joint swelling
Back pain
Limitation of movement
Muscle pains or cramps

Aesthetic Procedures I've previously had (check all that apply):

Botox/Dysport/Xeomin
Fillers (undereye, lips, etc)
Coolsculpting

I understand that all sales are final once payment is made. Fusion does not offer refunds.*

I agree

Signature