General New Patient Form Date* Date Format: MM slash DD slash YYYY Name* First MI Last Phone*Birthdate* Date Format: MM slash DD slash YYYY 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 supplementsHave you had any surgeries?*NoYesIf yes, then please list year(s) & surgeries below:Are you allergic to any medications?*NoYesIf yes:Do you use tobacco products?*NeverQuitYes, currentlyTypeNumber of days per weekN/A1234567Number of yearsPlease enter a number less than or equal to 100.Do you drink alcohol?*NoYesIf yes, how often?Other drug use?*NeverQuitYesGeneral (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
