العربية‎ ar

русский ru

Tiếng Việt vi

हिन्दी hi

简体中文 zh

Ελληνικά el

Home
About Us
Services
Payment Plans
Schedule
Blog
Rewards Program
Video Gallery
Contact Us
- Policies

(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

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

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

Content, including images, displayed on this website is protected by copyright laws. Downloading, republication, retransmission or reproduction of content on this website is strictly prohibited. Terms of Use | Privacy Policy

Share by: