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Morpheus8 Radio Frequency and Microneedling

Medical History

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Patient Information

Please fill out the following form.

Date of birth
Medical History
None
Anxiety
Blood Clots
Hepatitis C
Hypertension
Pregnant or Nursing
Myocardial Infarction
Seizure Disorder
Thyroid Disease
Other
Exercise and Activity
Moderate
Vigorous
Sedentary
Tobacco use
No
Daily
Weekly
Less
Former User
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
No, I am not
Are you allergic to any medication
Yes, I am (Please Explain)
No, I am not
Have you had surgery in the past 5 years
Yes, I am (Please Explain)
No, I am not
Previous Surgical History
None
Gastric Bypass
Bilateral Tubal Ligation
Hysterectomy
TAH/BSO
Others:
Medication due to allergies
Yes, I am (Please Explain)
No, I am not
Are you currently on mood altering or anti depression medications
Yes, I am (Please Explain)
No, I am not
Are you currently pregnanat or trying to get pregnant
Yes, I am
No, I am not
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