Patient Intake Form

Please answer each row of questions. Please list/explain: include medication dose/frequency, allergy type and reaction, and medical condition history (past/current)*

Rows	Yes	No	Please explain or list here:
Are you currently pregnant, nursing or trying to conceive?
Do you have/had any chronic illness, disease or conditions? Please list.
Do you take any medications including over the counter, vitamins and supplements? Please list.
Have you ever used Accutane or a similar medication in the last year?
Do you have a pacemaker or implanted electronic device or metal implant?
Do you have any allergies (beyond seasonal)? Please list.
Do you have a history of cold sores?

Yes, regularlyYes, but irregularlyNot anymore

YesNO

Let's Talk Symptoms

Rows	None	Sometimes	Often	Awful
Fatigue or Energy Loss
Dizziness or Headaches
Body Aches, Joint Pain or Frozen Shoulder
Mood, Anxiety, Rage, Depression
Racing Heart or Heart Palpitations
Low Libido
Urinary Incontinence
Increased Response to Allergies
Increased GI Problems
Brain Fog or Memory Loss
Weight Gain or Metabolism Changes
Burning Tongue, Dry Mouth/Thirst
Tingling or Shock Sensations
Skin, Hair, or Nail Changes
Vaginal Dryness, Itchiness or Painful Sex
Irregular Bleeding
Insomnia or Sleep Disruption
Hot Flashes and/or Night Sweats

Please list your preferred pharmacy and its address.

Lifestyle and Social History*

Rows	Yes	No	Please explain: weekly frequency, if you've quit and when.
Do you smoke?
Do you drink regularly?
Do you use recreational drugs?
Do you exercise?
Are you exposed to the sun regularly?
Are you exposed to heat regularly?
Do you do a lot of heavy lifting?

About The Treatment Area *

Rows	Yes	No
Has the treatment area been waxed or peeled in the last 7 days?
Have you used any retinol, acids or active medical products in the area in the last 7 days?
Has the treatment area had extended sun exposure in the last 2 weeks?
Do you have any active infections, rash, or injuries?

I consent to having photographs used for my medical record only. My photos cannot be shared.I consent to having photographs used by  Essential Advanced Skincare and Medspa IN OFFICE for education or marketing purposes.I consent to having photographs used for marketing purposes by Essential   Advanced Skincare and Medspa as long as my identity is concealed with eye blocks or cropping of my face. Essential can use these photos at their discretion for marketing purposes including social media, email, in office education, or website marketing.I consent to having photographs used freely for marketing purposes by Essential Advanced Skincare and Medspa. Essential can use these photos at their discretion for marketing purposes including social media, email, website marketing, continuing education or office education.

Signature*

Date*

MonthDayYear

Medical History

Essential Policies + Procedures