Medical History

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Personal Information
Step 1 of 6
First Name
Last Name
Date of Birth
Referred by
Address
City
Province
Postal Code
Country
Canadian Citizen?
Please contact the office to speak with one of our representatives.
Job Occupation

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Contact Information
Step 2 of 6
Home Phone
Work Phone
Cell Phone
Can Leave a Message at
Email Address
Health Card No. (& Version Code)
Emergency Contact Name
Emergency Contact Number

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Medical Condition History
Please select all of the following medical conditions you now have or have had in the past. If you have none, please select "None."
Step 3 of 6

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Medications, Supplements & Allergies
Step 4 of 6
Medication
Daily Dose
Frequency

Medication
Daily Dose
Frequency

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Medications, Supplements & Allergies
Step 5 of 6
Height
Units
Weight
Units
Are you now or have you ever been a smoker?
If you are an ex-smoker, for how long are you smoke free? (Years)
For how long did you smoke? (Years)
How much are (were) you smoking? (Cigarettes per day)
How much alcohol do you drink per week? (Servings)
How much caffeine do you drink per week? (Servings)
Do you have a history of cold sores?
When was your last outbreak of cold sores?
Do you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer?
If you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer, please explain:
Is there any possibility you may be pregnant at this time?
Please list all the surgeries that you have had (include plastic surgery and wisdom teeth removal) with the date you had the surgery.
Name of Surgery
Date of Surgery

Name of Surgery
Date of Surgery

Have you or anyone in your family ever had or have a history of unusual reactions or problems with LOCAL anesthesia (dental freezing). TOPICAL anesthesia (anesthetic creams or gels) or GENERAL anesthesia (rashes, muscle weakness, jaundice, breathing problems, or unexpected fevers(s)?
If yes, please explain:
Have you ever seen a cardiologist?
Physician Name
Date of Last EKG

Please fill out the entire form with your information. If you abandon the form the information you've input will not be saved, and you will have to start all over again.

Patient Signature
Step 6 of 6
I acknowledge that I have disclosed my complete medical history and the above is a complete and accurate representation of my medical and psychological status. I,
represent to the physicians and staff that I am at least 18 (eighteen) years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize a history examination by my doctor and such assistant or staff as may be assigned by him/her. If appropriate, I authorize the release of any medical information for the purpose of processing insurance claims on my behalf. I authorize payments of medical benefits directly to the doctor for services provided to me. A copy of this authorization shall be considered as valid as the original. I understand that photography is a necessary part of planning and evaluating cosmetic procedures. I authorize the taking of photographs at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs wil be used solely for documentation purposes and will be kept confidential unless otherwise disclosed. I understand that there is a consultation fee for the initial visit which is due at the time of my appointment unless other arrangements have been made in advance.
Signature
Date
Relationship (select one):

Please review all your information. Make any changes by clicking the edit button for that section.

Step 1 of 6
Personal Information
First Name:
Last Name:
Date of Birth:
Referred By:
Address:
City:
Province:
Postal Code:
Country:
Canadian Citizen:
Occupation:
Step 2 of 6
Contact Information
Home Phone:
Work Phone:
Cell Phone:
Can leave a message at:
Email Address:
Health Card No. (& Version Code):
Emergency Contact Name:
Emergency Contact Number:
Step 3 of 6
Medical Condition History
Bleeding Tendency: No
Diabetes: No
Blood Transfusions: No
Glaucoma: No
Dry Eyes: No
Lung Disease: No
TB: No
Asthma or Wheezing: No
Emphysema: No
Bronchitis:
Irregular Heart Beat: No
Chest Pain: No
Heart Disease: No
High Blood Pressure: No
Pace Maker: No
Heart Attack: No
Stroke: No
Epilepsy: No
Heart Burn: No
Intestinal Ulcurs or Bleeding: No
Rheumatoid Arthritis: No
Skeroderma: No
Lupus: No
Porphyria: No
Depression: No
Mental Illness: No
Drug or Alcohol Addiction: No
Hepatitis B: No
Hepatitis C: No
HIV: No
Contact Lenses: No
Loose or Chipped Teeth: No
Dentures: No
Dental Implants: No
Caps: No
None: No
Any Other Serious Illness or Injury: Please check this box and explain in the field below: No
Step 4 of 6
Medications, Supplements & Allergies
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Please list all Naturopathic, Health Food Supplements and Vitamins:
Please list all ALLERGIES including LATEX:
Step 5 of 6
Health & Surgical History
Height:
Units:
Weight:
Units:
Are you now or have you ever been a smoker?: No
If you are an ex-smoker, for how long are you smoke free? (Years):
For how long did you smoke? (Years):
How much are (were) you smoking? (Cigarettes per day):
How much alcohol do you drink per week? (Servings):
How much caffeine do you drink per week? (Servings):
Do you have a history of cold sores? No
When was your last outbreak of cold sores?
Do you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer?: No
If you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer, please explain:
Is there any possibility you may be pregnant at this time?: No
Please list all the surgeries that you have had (include plastic surgery and wisdom teeth removal) with the date you had the surgery.
Name of Surgery:
Date of Surgery:
Name of Surgery:
Date of Surgery:
Have you or anyone in your family ever had or have a history of unusual reactions or problems with LOCAL anesthesia (dental freezing). TOPICAL anesthesia (anesthetic creams or gels) or GERERAL anesthesia (rashes, muscle weakness, jaundice, breathing problems, or unexpected fevers(s)?
If yes, please explain:
Have you ever seen a cardiologist?
Physician Name:
Date of Last EKG:
Step 6 of 6
Patient Signature
I acknowledge that I have disclosed my complete medical history and the above is a complete and accurate representation of my medical and psychological status. I,
represent to the physicians and staff that I am at least 18 (eighteen) years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize a history examination by my doctor and such assistant or staff as may be assigned by him/her. If appropriate, I authorize the release of any medical information for the purpose of processing insurance claims on my behalf. I authorize payments of medical benefits directly to the doctor for services provided to me. A copy of this authorization shall be considered as valid as the original. I understand that photography is a necessary part of planning and evaluating cosmetic procedures. I authorize the taking of photographs at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs wil be used solely for documentation purposes and will be kept confidential unless otherwise disclosed. I understand that there is a consultation fee for the initial visit which is due at the time of my appointment unless other arrangements have been made in advance.
Signature:
Date:
Relationship (select one):
Thank You!
Your form has been submitted. If you have any questions or concerns, please feel free to contact the SpaMedica team with the contact information below.