Aesthetics Patient Information & Medical History
Patient Name:
*
First Name
Last Name
Date:
*
Sex:
*
Male
Female
Date of Birth:
*
Address:
*
Street number, Street Name, apt/suite number if applicable
City:
*
State:
*
Zip:
*
Home phone #:
Cell phone #:
*
Work phone #:
Email:
example@example.com
Please indicate if we may contact you at:
Home phone
Cell phone
Work phone
Email
Please indicate if we may leave detailed messages for you at:
Home phone
Cell phone
Work phone
Email
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Relationship to You:
*
Are you currently pregnant?
*
Yes
No
If yes, how many months?
Are you currently breastfeeding?
*
Yes
No
Do you smoke?
*
Yes
No
If yes, how much?
Have you ever had melanoma?
*
Yes
No
Have you ever had other skin cancer?
*
Yes
No
Do you have a family history of melanoma?
*
Yes
No
Do you have a family history of other skin cancers?
*
Yes
No
If yes, what is the relationship to you?
(For example: mother, brother)
What is your average UV (sun) exposure?
When was your most recent UV (sun) exposure?
How frequently do you wear sunscreen?
Always
Often
Sometimes
Rarely
Never
Have you ever sunburned?
Yes
No
If yes, when?
Do you use sunless tanner?
Yes
No
If yes, how recently?
What skin care products do you use?
Are you or have you taken Accutane or Isotretinoin?
Yes
No
(oral vitamin A)
If yes, how recently?
What medications are you taking?
Do you have any drug allergies?
Have you had facial surgery?
Yes
No
If yes, please explain.
Have you ever had Botox/Dysport/Jeuveau injections?
Yes
No
If yes, when was the most recent?
Have you ever had dermal filler injections?
Yes
No
If yes, when was the most recent?
Please indicate if you have had any of the
followin
g
medical conditions recently.
Have you had cold sores?
Yes
No
If yes, when was the most recent outbreak?
Have you ever had MRSA?
Yes
No
If yes, when was your most recent outbreak?
New or changing mole
Yes
No
Skin healing problems?
Yes
No
Keloids (painful, thick surgical scars)
Yes
No
Skin rash
Yes
No
Fever
Yes
No
Extreme fatigue
Yes
No
Unexplained weight gain/loss
Yes
No
Swollen glands
Yes
No
Excessive thirst
Yes
No
Thyroid disorders
Yes
No
Allergies to bandages/tape
Yes
No
Other allergies
Yes
No
Migraines
Yes
No
Other headaches
Yes
No
Seizures
Yes
No
Dry throat/mouth
Yes
No
Asthma
Yes
No
High blood pressure
Yes
No
Heart Pain
Yes
No
Vascular disease
Yes
No
Muscle or joint pain
Yes
No
Anemia
Yes
No
Bleeding problems
Yes
No
Bruising easily
Yes
No
Anxiety disorder
Yes
No
Bipolar disorder
Yes
No
Obsessive compulsive disorder
Yes
No
Depression
Yes
No
Other psychiatric conditions
Yes
No
If yes to any of the above, please provide more information:
List any other significant medical history:
How did you hear about us?
Doctor Referral
Family/friend Referral
Website
Facebook
Magazine Ad
Radio Ad
Phone book
Submit
Should be Empty: