• Client Medical History Assessment

    In order to provide you with the most appropriate treatment we need you to complete thefollowing questionnaire. ALL information is strictly confidential.
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -

  • May we contact you via: 

    Note: We will not send spam or share your email with any other party.

  • Mail*
  • Email*
  • Telephone*
  •  -

  • Patient Medical History

  • Health issues and procedures/ products of interest to you (Please check all that apply)*

  • Cosmetic/Aesthetic History:

  • 1) How would you describe your skin?*
  • 2) Describe your skin type:*
  • 3) Have you ever had any facial surgery preformed?*
  • 4) Have you ever had any type of Aesthetic Procedure?*
  • 5) Have you ever had any complications with any aesthetic procedures/treatments in the past?*
  • 6) Have you ever had any of the following injectable procedures done?*

  • Medical and Family History:

  • 1) Are you currently under the care of a physician?*
  • 2) Are you currently under the care of a dermatologist?*
  • 3) Do you have any of the following medical conditions? (Please check all that apply):*
  • 4) Does anyone in your family have a chronic skin condition?*
  • 5) Does anyone in your family have a chronic pigmentation disorder?*
  • 7) Have you been diagnosed (past/present) with depression, anxiety, panic attacks, or other psychiatric issues?*

  • Social History:

  • 1) Do you drink alcohol?*
  • 2) Do you smoke?*
  • 3) Do you exercise?*
  • 4) Please describe your diet:*
  • 5) Are you pregnant?*
  • 6) Are you currently breastfeeding?*
  • 7) Are you planning to become pregnant?*

  • Medication and Allergies:

  • 1) Please list ALL medications (including OTC) you are currently taking:*

  • 2) Have a pacemaker, internal defibrillator, or other implanted device?*
  • 3) Have you ever used Accutane?*

  • I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the health care providers at RENEW of my current medical or health conditions and to update this history with any changes. I understand that my current medical is essential to determine and carry out any appropriate treatments or procedures.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: