Medical Contraindications Intake Form
Please complete this form to help us identify any medical contraindications before your care or treatment. Your responses will assist your provider in delivering safe and appropriate medical attention.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Symptoms or Reason for Visit
*
Relevant Medical History (select all that apply)
*
Heart disease
High blood pressure
Diabetes
Asthma or lung disease
Kidney disease
Liver disease
Cancer
Autoimmune disorder
None of the above
Other
Known Allergies (select all that apply)
*
No known allergies
Medications
Latex
Foods
Environmental (e.g., pollen, dust)
Other
If you selected any allergies, please specify the allergen(s) and describe your reaction(s)
Current Medications and Supplements (please list all, including over-the-counter and herbal products)
*
Are you currently pregnant or breastfeeding?
*
Not applicable
Pregnant
Breastfeeding
Neither
Have you had any recent procedures, surgeries, or treatments?
*
No
Yes (please specify below)
If yes, please describe your recent procedures, surgeries, or treatments
Have you experienced any prior adverse reactions or contraindications to medical treatments?
*
No
Yes (please specify below)
If yes, please describe the adverse reaction(s) or contraindication(s)
Is there any additional health information your provider should know?
Submit
Should be Empty: