Dr Johnsons Regular Repeat Patient Medical History Update Form

Dr Teri Johnson's Medical History Update Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Birth
Mobile phone*
Any changes to your medical health or medication?*
Please list all medication you are currently taking including herbal remedies:*
Is there any possibility of pregnancy or are you breast feeding?*

YesNo
Are you undergoing or due to have any dental treatment?*

YesNo
Please tell us about your problem/ reason for attending a consultation with us today so that we can customise your appointment to meet your specific needs and concerns.*
What concerns have made you decide to have treatment?*

Appearance affecting lifeAppearance affecting relationshipAppearance affecting workDepressed about appearanceDepressive thoughts related to concernsFeeling insecureFeeling embarrassed about appearanceFeeling oldFeeling saggyLow self-esteemPremature ageingPremature skin ageingPremature skin laxityPremature volume loss in faceSmoking-related skin damageSocial anxiety related to appearanceUnhappy about appearanceUnhappy about AsymmetryUV related skin damageWant to feel better about selfWant to look less angryWant to look less sadWant to look less tiredWorried about the effects of oestrogen deficiency.Worry about appearanceOther

Out of 5, where 5 is very much and 0 is not at all. How much does your problem bother you?*

	1	2	3	4	5

1 is Worst, 5 is Best

Can you explain why it bothers you?
Where 5 is very much and 0 is not at all. How much do you think it affects the following?

Your self-esteem *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

How much does it impact you psychologically*

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Does/ will your treatment help you psychologically?*

YesNo
Does/ will your treatment help you in any other way?*

YesNoOther
Any other comments:
I confirm I have read and understood the medical questionnaire. I have completed it accurately and discussed all past and present medical conditions with the treating doctor. I am aware that withholding medical information could have a detrimental effect on both my treatment and my health.
I have read the clinics terms and conditions and I am happy to adhere to the 48hr cancellation policy in place.
Please sign

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Dr Teri Johnson's Medical History Update Form