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Delta Wellness Basic Medical History Form

Member Information

• Full Name: {name}

• Date of Birth: {dob}

• Phone Number: {phone}

• Address: {address}

• Emergency Contact Name: {contact_name}

• Emergency Contact Phone: {contact_phone}

• Emergency Contact Relation: {contact_relation}

Medical Provider Information

• Primary Care Physician: ____________________

• Clinic / Hospital: ____________________

• Phone: ____________________

Medical History

• Pregnant or Breastfeeding

• Have you ever been diagnosed with any of the following? (Check all that apply):

  • Diabetes | High Blood Pressure | Heart Disease

  • Asthma | Stroke | [ ] Cancer | Thyroid Disorder

  • Kidney Disease | Liver Disease

  • Mental Health Conditions (e.g., anxiety, depression)

  • Neuromuscular disorders (e.g., ALS, Myasthenia Gravis)

  • ] Epilepsy or Photosensitive Seizures

  • Active Cancer or undergoing radiation/chemotherapy

  • Severe or uncontrolled Cardiovascular issues

  • History of deep vein thrombosis or bleeding disorders

  • Cold allergy or Cold-induced conditions (e.g., Raynaud's)

  • Heat sensitivity or heat-induced conditions (e.g., MS, Lupus)

  • Use of medications that cause photosensitivity

  • Active infection or open wounds in treatment area

  • ] Hernia or recent abdominal/pelvic surgery

  • Allergy to Botulinum Toxin or any of its ingredients

  • Other: ____________________

Surgical History

• Surgeries and Dates: ____________________

• Implanted electronic or medical devices (Circle all that apply): Pacemakers, defibrillators, neurostimulators, metal implants, copper IUDs.

Medications & Allergies

• Current Medications: ____________________ (List all prescriptions, OTC, and supplements)

• No known allergies

• Medication Allergies: ____________________

• Food/Environmental Allergies: ____________________

Lifestyle Information

• Do you smoke? Yes No

• Do you drink alcohol? ] Yes No

• Do you exercise regularly? Yes No

Signatures

• Additional Notes: ____________________

• Client's Signature: ____________________

• Date: {sign_date}