DEMOGRAPHICS AND MEDICAL HISTORY

DEMOGRAPHICS AND MEDICAL HISTORY
Patient Name
Date of Birth

Month Day Year
Date
Age:
Primary Care Doctor
Referred by:
Address

Street Address

Street Address Line 2

City State / 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:
Do you have or have you ever experienced any of the following?

Anemia Asthma Arthritis Active Infection Bleeding/ Blood Clots Cancer Currently Nursing Diabetes Frequent Cold Sores Herpes HIV/AIDS Hepatitis High Blood Pressure Hormone Imbalance Keloid Scarring Pregnant, or trying Seizure Disorder Thyroid Imbalance Skin Lesions/disease Other:
ALLERGIES
Have you ever had an allergic reaction? (List any and describe the reaction you experienced)

Aspirin Lidocaine Hydroquinone Glycolic Local Anesthetics Skin bleaching Agents Retinols
MEDICATIONS
Please list all the medications you are currently taking. Please include prescriptions, topicals, birth control, hormones, vitamins and supplements.
TOPICS OF INTEREST TO YOU:

Active Acne Acne Scarring Blackheads/pores BOTOX Chemical Peels Dermaplane Facial Veins Fillers Hair Removal (laser) Hair Restoration IPL Latisse/lashes Laser Genesis Leg Veins Loss of Elasticity Microneedling Pigment/Brown Spots Platelet Rich Plasma Spider Veins Weight Loss Wrinkles/Fine Lines
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

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

DEMOGRAPHICS AND MEDICAL HISTORY

ALLERGIES

MEDICATIONS