Patient Medical / Surgical History

Current Medical Condition(s), please enter N/A if not applicable:

Past Medical History, please enter N/A if not applicable:

Past - Surgical History, please enter N/A if not applicable:

Allergies (eg. Medication, Food, Environment), please enter N/A if not applicable::

Current Medication(s) (eg. Prescription, Supplement, Over- the- Counter, Medical Cannabis):

COVID Vaccine (Most Recent Date), please enter N/A if not applicable:

Alcohol Use (Amount/ Frequency), please enter N/A if not applicable:

Nicotine Use (eg. Smoke, Chew, Vape) (Amount / Frequency), please enter N/A if not applicable:

Other Drug Use (Type/ Amount/ Frequency), please enter N/A if not applicable:

Emergency Contact:

First Name

Last Name

Relationship

Phone

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