Style 4 Demo

Your clinician uses this information to care for you safely. If you're not sure about an answer, choose "Not sure" or add a note, and we'll go over it with you at your visit.

Patient Name *

Date of Birth *

Email *

Your primary care physician or other clinicians treating you (name and phone)

Conditions: tick any you have now or have had

Heart condition (heart disease, heart attack, valve problem, murmur or pacemaker)

High or low blood pressure

Stroke

Bleeding problems, easy bruising or anemia

Diabetes

Asthma, COPD or another lung condition

Kidney disease

Liver disease or hepatitis

Thyroid condition

Seizures or epilepsy

Arthritis, or an artificial joint or other implant

Osteoporosis

Cancer, now or in the past (including radiation or chemotherapy)

HIV or another condition that affects the immune system

Acid reflux, ulcers or other stomach problems

Sleep apnea

A mental health condition (for example, anxiety or depression)

Any other conditions, or details about the ones above

Past surgeries or hospital stays (what and when)

Have you ever had a problem with anesthesia (numbing or sleep medicine)?

No

Yes

Not sure

What happened?

Medicines

Medicines you take, including prescription and over-the-counter medicines, vitamins and supplements (name and dose if you know it)

Do you take a blood thinner (for example, warfarin, apixaban or a daily aspirin)?

No

Yes

Not sure

Have you ever taken a medicine for bone loss, or a cancer medicine that affects bone (for example, alendronate, zoledronic acid or denosumab)?

No

Yes

Not sure

Do you take a weight-loss or diabetes medicine such as semaglutide or tirzepatide?

No

Yes

Not sure

Allergies

Do you have any allergies (medicines, latex, foods or anything else)? *

No known allergies

Yes

Not sure

What are you allergic to, and what happens when you're exposed? *

Other

Are you pregnant or breastfeeding?

No

Yes

Not sure

Doesn't apply to me

Tobacco or vaping

Never

In the past

Now

Anything else your clinician should know about your health?

The information I gave is accurate to the best of my knowledge, and I will tell my clinician about any changes. *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 4 Demo for a paper copy of this form at any time.

Date *

Signature *

Medical History

Medical History

Conditions: tick any you have now or have had

Medicines

Allergies

Other