Advance Biomedical Treatment Center
35 Jolley Drive Suite no.102
Bloomfield, CT 06002
Name: _________________________________________________________ Date of Birth: ______________
Prior VERJU Therapy ___ Yes ___ No Date Last Treated __________ Area____________________________________
VERJU 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
Cancer Treatment ___ Yes ___ No
Coagulation Issue ___ Yes ___ No
Hepatitis (Type __ ) ___ Yes ___ No
HIV / AIDS ___ Yes ___ No
Herpes I / II ___ Yes ___ No
Keloids ___ Yes ___ No
Photosensitizing med ___ Yes ___ No
Pacemaker ___ Yes ___ No
Diabetes ___ Yes ___ No
Open Wound on Site ___ Yes ___ No
By signing below, I certify that the above information that I have provided is true.
Patient Signature: ___________________________________________ Date Signed: ___________________
