Fillable TEMPSURE MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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TEMPSURE MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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Advance Biomedical Treatment Center
35 Jolley Drive Suite no.102
Bloomfield, CT 06002
Name: ________________________________________________ Date of Birth: ___________
Prior TempSure Therapy ___ Yes ___ No Date Last Treated __________ Area_________________
TEMPSURE MEDICAL QUESTIONNAIRE
Current Medical Problems:
1. _________________________________________ 5. __________________________________________
2. _________________________________________ 6. __________________________________________
3. _________________________________________ 7. __________________________________________
4. _________________________________________ 8. __________________________________________
Past Medical / Surgical History:
1. _________________________________________ 5. __________________________________________
2. _________________________________________ 6. __________________________________________
3. _________________________________________ 7. __________________________________________
4. _________________________________________ 8. __________________________________________
Current Medications:
1. _________________________________________ 5. __________________________________________
2. _________________________________________ 6. __________________________________________
3. _________________________________________ 7. __________________________________________
4. _________________________________________ 8. __________________________________________
Current Supplements/Vitamins/Herbs/Homeopathic remedies:
1. _________________________________________ 5. __________________________________________
2. _________________________________________ 6. __________________________________________
3. _________________________________________ 7. __________________________________________
4. _________________________________________ 8. __________________________________________
Allergy to Medications: ___ YES ___ NO
If Yes, what? _____________________________________________________________________
Are you currently pregnant? ___ Yes ___ No ___ Not Sure
Do you have any of the following?
Active Infection ___ Yes ___ No
Autoimmune Dis. ___ Yes ___ No
Alcohol Intoxication ___ Yes ___ No
Nerve Insensitivity ___ Yes ___ No
Blood thinner Use ___ Yes ___ No
Herpes Simplex ___ Yes ___ No
Use of Pain Killers ___ Yes ___ No
Implantable devices ___ Yes___ No
Pacemakers ___ Yes ___ No
Diabetes ___ Yes ___ No
Wound in Area ___ Yes ___ No
By signing below, I certify that the above information that I have provided is true.
Patient Signature: ______________________________________ Date Signed: ___________________
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TEMPSURE MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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Completed 25 May 2021

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