Medical History Form — Bogat Aesthetics & Wellness

Patient Information

Fields marked with * are required

* First Name

Middle Name

* Last Name

* Date of Birth

* Email

* Occupation

* Driver License #

* Height

* Weight

* Sex

Male

Female

Address

* Address Line 1

Address Line 2

* City

* State

* Zip

Phone Numbers

* Cell Phone

Best Time to Call

Home Phone

Best Time to Call

Work Phone

Best Time to Call

Primary Physician Information

Physician's Name

Phone

Date of Last Physical Exam

* Last Blood Work Date

Bogat Aesthetics Contact

Have you already contacted Bogat Aesthetics & Wellness?

Name of Your Clinical Advisor

Family History

Does an immediate family member currently have or ever had any of the following?

Cardiovascular disease

Diabetes, Thyroid or Endocrine Disorder

Hypertension

Other forms of cancer

Lipid Disorder

Other illnesses

Please explain family health history

Lifestyle Information

* Do you smoke?

How much per day?

* Do you drink alcohol?

How much per week?

* Do you exercise regularly?

Please describe

Allergies

* Do you have any allergies?

List all allergies (medications, food, environmental). Include name, reaction, and severity.

Diagnosed History of Disease

Do you currently have or ever had any of the following?

Known deficiency (minerals/electrolytes)

Poor wound healing

Use of medications

Emotional disorders / depression

Blood disorders

Renal disease

Immune disorders

Genital - Urinary disorder

Cancer

Hyperlipidemia

Chemical Dependency

Hypertension

Carpal Tunnel syndrome

Neurological disorders

Lung disorder

Thyroid / Diabetes / Endocrine disorder

Orthopedic or muscle disorder

Arthritis

Heart disease incl. Atherosclerosis

Bursitis

Allergies to Medications

Rheumatism

Upper respiratory

Sports Injury

Edema / excess fluid retention

Other illnesses

Explain the history of any above checked diseases

Over-the-Counter Supplements

* Do you take over-the-counter supplements?

List name and quantity per day/week

Current Medications

Please be specific — name, dosage, etc.

* List all medications (or specify "none")

Questions for Treatment

Do you currently have or ever had any of the following symptoms?

Important Notice

Bogat Aesthetics & Wellness and its physicians do not treat patients for athletic performance or enhancement. We do not treat bodybuilders or professional athletes. We do not treat those currently in any branch of military service (active duty or reservist) or those anticipating entering the military while taking any prescribed therapeutic program.

Increased lack of drive

Currently Pregnant

Increasing fat deposits (abdomen/thighs)

Depression

Increasing mood swings

Difficulty sleeping

Increasing sagging muscles or breasts

Headaches / Migraines

Increasing wrinkles

Hot flashes

Increasingly stressed

Loss of concentration / sociability

Decreased desire to exercise

Loss of interest in sex

Decreased energy or endurance

Muscle loss

Decreased sense of well-being

Sagging, loose or thin skin

Decreasing memory

Sore muscles / joint pain / swelling

Decreasing muscle strength

Thinning or loss of hair

Urogenital atrophy

Progressive osteoporosis / stooped posture

Weight loss - Unexplained

Cold or heat intolerance

Other

Please explain any additional information

Patient Acknowledgment

Please review and accept each of the following statements

I certify that the information provided in this form is accurate and complete to the best of my knowledge.

I understand that this information will be used to determine appropriate treatment options.

I agree to notify Bogat Aesthetics & Wellness of any changes to my medical history.

I am seeking this treatment for legitimate medical purposes.

Electronic Signature

Your signature is legally binding under the U.S. ESIGN Act and Florida UETA

Electronic Signature Disclosure

By signing below, you consent to sign this Medical History Form electronically. Your electronic signature carries the same legal weight as a handwritten signature pursuant to the Electronic Signatures in Global and National Commerce Act (ESIGN, 15 U.S.C. § 7001) and the Florida Uniform Electronic Transaction Act (F.S. § 668.50). A record of your signature, including timestamp and verification data, will be securely stored with your submission.

* Full Legal Name (type to confirm)

* Confirm Date of Birth

* Patient Signature — draw with your finger or stylus

Sign here

Timestamp will be captured on submit

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Thank You

Your medical history form has been submitted successfully. Our team will review your information and be in touch shortly.

Bogat Aesthetics & Wellness
800 N Federal Hwy, Suite 805, Hallandale Beach, FL 33009
(954) 900-9090