Brief Medical History Form - Cobb Wellness and Aesthetics

Name *

Phone Number *

Date of Birth *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What are your goals? *

What is your height and weight? *

If you want to lose weight, how much do you want to lose? *

Please list any medical problems: *

Are you under the care of another physician for any medical condistions? *

If so, what for?

Please list any prior surgeries? *

Medications and dosages: *

Supplements and how often you take them: *

Are you having any GI symptoms – bloating, gas, indigestion? *

If so, please explain

Please check off any symptoms if you have ever has any of these conditions: *

If other, please explain

Do you have any drug allergies? *

If so, what are you allergic to?

Any family medical history: *

Do you smoke? *

Do you have any history of cancer? *

If so, what type and when?

Do you drink alcohol? *

If so, how often?

Do you affirm that you have answered all questions truthfully and to the best of your knowledge? *