DEMOGRAPHICS AND MEDICAL HISTORY

DEMOGRAPHICS AND MEDICAL HISTORY
Patient Name
Date of Birth

MonthDayYear
Date
Age:
Primary Care Doctor
Referred by:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Cell #:
Emergency Contact:
What is the purpose of your visit today?
What medical problems do you have? Please include anything for which you have been hospitalized, seen a physician or take medication:
AnemiaAsthmaArthritisActive InfectionBleeding/ Blood ClotsCancerCurrently NursingDiabetesFrequent Cold SoresHerpesHIV/AIDSHepatitisHigh Blood PressureHormone ImbalanceKeloid ScarringPregnant, or tryingSeizure DisorderThyroid ImbalanceSkin Lesions/diseaseOther:
ALLERGIES
AspirinLidocaineHydroquinoneGlycolicLocal AnestheticsSkin bleaching AgentsRetinolsOther
MEDICATIONS
Please list all the medications you are currently taking. Please include prescriptions, topicals, birth control, hormones, vitamins and supplements.
Active AcneAcne ScarringBlackheads/poresBOTOXChemical PeelsDermaplaneFacial VeinsFillersHair Removal (laser)Hair RestorationIPLLatisse/lashesLaser GenesisLeg VeinsLoss of ElasticityMicroneedlingPigment/Brown SpotsPlatelet Rich PlasmaSpider VeinsWeight LossWrinkles/Fine LinesOther
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

DEMOGRAPHICS AND MEDICAL HISTORY

ALLERGIES

MEDICATIONS