Search Schedule a Visit (561) 931-2430

Book Now Menu

Hormone Therapy
Aesthetics
Sexual Health
Wellness

About
Forms
Contact

(561) 931-2430

Book Now

Search

Hormone Therapy
Aesthetics
Sexual Health
Wellness

About
Forms
Contact

(561) 931-2430

Search for:

Hormone Therapy
Aesthetics
Sexual Health
Wellness

(561) 931-2430

Search Schedule a Visit

Medical History Form

Please fill out the form below entirely. Contact our office if you have any questions/concerns.

Patient Information
Full Name*
Street Address*
City*
State*
Zip Code*
Phone Number*
Email Address
Marital Status*
- Single
- Married
- Divorced
- Widowed
Sex*
- Male
- Female
- Other
Ethnicity*
- Hispanic or Latino
- Non Hispanic or Latino
- Unknown
Date of Birth*
MM slash DD slash YYYY
Age*
Student/Employer*
Employer Phone*
Employer Street Address*
Employer City*
Employer State*
Employer Zip Code*
Whom may we thank for referring you?
Family Doctor*
Preferred Pharmacy*
In case of emergency, who should be notified?*
Emergency contact relationship to patient*
Emergency contact phone number*
Legal Guardian if patient is under 18 years old
Legal Guardian's phone number
Legal Guardian's date of birth
MM slash DD slash YYYY
New Patient Health Questionnaire
First & Last Name*
Date of Birth*
MM slash DD slash YYYY
Age*
New or returning patient?*
- New Patient
- Established
PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.
What medical concerns bring you to our office?*
Marital Status*
- Single
- Married
- Divorced
- Widowed
Occupation (if retired, previous occupation)*
Are you disabled?*
- Yes
- No
Birthplace*
Do you exercise regularly?*
- Yes
- No
Have you ever smoked?*
- Yes
- No
Have you completed an advanced directive or do you have a living will?*
- Yes
- No
Do you drink caffeinated coffee, teas, or sodas regularly?*
- Yes
- No
Tell us a little about your home environment*
Are you under a lot of pressure at work or home? If yes, which one?*
Medical Information
Are you allergic to any drugs?*
- Yes
- No
Medications
List all medications that you are taking currently. Include over the counter, herbal or natural remedies.
Medical Illness or Conditions
List any chronic conditions which you have been diagnosed to have
Have you ever had or been diagnosed to have:
Select all that apply.
- Cataracts
- Glaucoma
- Asthma
- Allergies
- Stroke
- Seizures/Epilepsy
- Heart Attack or Angina
- Heart Disease
- Heart Murmur
- High Blood Pressure
- Pneumonia
- TB/Lung Disease
- Pleurisy
- Jaundice or Liver Disease
- Ulcers
- Digestive Disorder
- Hemorrhoids
- Kidney Disease
- Kidney Stone(s)
- Diabetes or PreDiabetes
- Thyroid Disease
- Anemia
- Bleeding Disorders
- Bone or Joint Disease
- German Measles
- Rheumatic Fever
- Chicken Pox
- Syphilis
- Depression
- Frequent Infection
- Cancer
- High Cholesterol
- Prostate Enlargement
- Other
Specify other
Operations
Please list any surgery, hospital, and approximate year
Hospitalizations (other than operations)
Please list any reason, hospital, and approximate year
Family Medical History
Please List The Following for Each Family Member:
1. Relation (Father, Mother, Sister, Brother, Spouse, Children) 2. Age of Relative 3. Any Significant Illness 4. If Deceased, Cause. 5. Any Additional Comments.
Has Any Blood Relative Ever Had?
Check if yes and indicate relationship
- Alzhemer's
- Tuberculosis
- Diabetes
- High Blood Pressure
- Heart Disease
- Heart Attack Before Age 55
- Bleeding Disease
- Stroke
- Seizures
- Depression/Suicide
- Alcoholism
- Mental Disorder
- Allergies
- Asthma
- Cancer
What's Your Relationship to the Relatives With Above Condition(s)?
Immunizations*
- Influenza
- Pneumonia
- MMR
- Tetanus
- Hepatitis A or B
- Other
- Bleeding Disease
- Stroke
- Seizures
- Depression/Suicide
- Alcoholism
- Mental Disorder
- Allergies
- Asthma
- Cancer
Specify other
Have you ever had a blood or plasma transfusion?*
- Yes
- No
What is your weight now?*
What was your weight one year ago?*
What has been your maximum weight?*
When were you that maximum weight?*

Location

LifeGaines Medical Spa & Aesthetics

3785 N Federal Hwy Suite 150, Boca Raton, FL 33431

View larger map

Get Directions Call (561) 931-2430

Book your consultation.

First & Last Name*
Phone Number*
Email Address
What brings you to LifeGaines?*
Newsletter Subscribe
Subscribe to our newsletter
CAPTCHA

Services
About

Location

3785 N Federal Hwy
Suite #150, Boca Raton,
FL 33431

(561) 931-2430
info@lifegaines.com

©2025 Life Gaines - Privacy Policy | Sitemap

DISCLAIMER: This website is an educational service that provides general health and wellness information only. It is not intended to diagnose, treat or cure any health related condition. Please always consult a physician regarding your health before starting any health or diet program. No medical treatment can guarantee results. Results vary from patient to patient. We encourage you to do your own research, ask questions, and review board certifications and testimonials on any similar websites describing similar therapies. Statements made on this website have not been evaluated by the Food and Drug Administration. The information contained herein is not intended to diagnose, treat, cure, or prevent any disease.

Cleantalk Pixel

Chat with usLiveChat

(561) 931-2430