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(571) 244-0052

Se Habla Español

(289) 992-8486 Whatsapp

Medical History

Medical History Form for Our Body Sculpting Clinic

Patient Information

First Name*

Last Name*

Email*

Date of Birth*

Medical History*

None

Anxiety

Blood Clots

Hepatitis C

Hypertension

Pregnant or Nursing

Myocardial Infarction

Seizure Disorder

Thyroid Disease

Other

Exercise Activity*

Moderate

Vigorous

Sedentary

Tobacco Use*

No

Daily

Weekly

Less

Former User

Alcohol Use*

No

Daily

Weekly

Less

Former User

Are you currently taking supplements or prescription medication?*

Yes, I am.

I do not take any medications.

Are you allergic to any medications?*

No

Yes. Please list

Other:

Have you had any surgeries in the past 5 years?*

Yes

No

Other

Previous Surgical History*

None

Gastric Bypass

Bilateral Tubal Ligation

Hysterectomy

TAH/BSO

Others:

Medications due to allergies*

Yes

No

Other

Are you currently on any mood altering or anti-depression medication?*

Yes

No

Are you currently pregnant, nursing or trying to get pregnant?*

Yes

No

Signature of Patient/Responsible Party

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Contact US

Phone: (571) 244-0052

International
(Dubai, Saudi Arabia, Qatar)

Patients Contact Us:
Whatsapp: 1-571-244-0052

Se Habla Español:

Whatsapp: 1-289-992-8486

Email: info@bodysculptva.com

Address:

8000 Towers Crescent Dr, 13^th Floor

Tysons, VA 22182

Business Hours

Mon - Sun: 8:00 am - 8:00 pm

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Discover Payment Accepted

Cash Payment Accepted

Location in tysons corner

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