EMS Medical History Form

Patient Information

Full Name: ____________________________________________

Date of Birth (DOB): __________________________________

Address: ________________________________________________________

Phone Number: ________________________________________

Email Address: ________________________________________

Emergency Contact Information

Name: ____________________________________________

Relationship: ______________________________________

Phone Number: _____________________________________

Please answer the following questions accurately. This information is essential for your safety and to determine your suitability for EMS treatments.

Do you have any of the following conditions? (Tick all that apply or put Yes or No):

Have you experienced any of the following symptoms or issues?

Are you currently taking any medications, supplements, or herbal remedies?

Do you have any allergies (medications, adhesives, latex, etc.)?

Have you undergone any recent medical or aesthetic treatments (e.g., surgery, laser, injections)?

Do you have a history of weight fluctuations or significant recent weight changes?

Do you exercise regularly?

Are you following any specific dietary plans or restrictions?