Patient Medical Form
Patient:
*
First Name
Middle Name
Last Name
Occupation:
*
Emergency Contact Name:
*
Emergency Contact Phone:
*
Who may we thank for referring you?
We specialize in a number of cosmetic procedures. Are you also interested in scheduling a consultation for any of the following? PLEASE CHOOSE
Laser treatment of wrinkles, broken blood vessels or brown spots
Yes
No
Treatment of deep wrinkles with Juvederm, Radiesse, Belotero, Restylane or fat
Yes
No
Liposuctions (Tumescent)
Yes
No
Eyelid lift or Mini facelift for jowls and neck
Yes
No
Botox treatment of frown lines or crow’s feet
Yes
No
Spider (leg) vein treatment
Yes
No
Dermatology-related health questions
Previous Dermatologist:
Previously diagnosed skin condition
*
Yes
No
If YES, what condition(s)?
History of skin cancer
*
Yes
No
If YES, what condition(s)?
(basal cell carcinoma, squamous cell carcinoma, melanoma, other)
History of pre-cancers
*
Yes
No
If YES, what condition(s)?
(actinic keratoses or abnormal moles – atypical or dysplastic)
Family history of skin cancer
*
Yes
No
If YES, what type?
If YES, who?
Has anyone in your family had a MELANOMA?
*
Yes
No
If YES, who?
How many sunburns have you had since childhood?
*
Do you use sunscreen (choose one)?
*
Always
Sometimes
Never
Do you work outdoors?
*
Skin type:
*
Fair
Medium
Dark
Ethnicity:
*
Place of Birth:
*
General Health Questions
Current Medication(s):
Are you prone or do you have any of the following conditions?
PLEASE CHOOSE
Smoker
*
Yes
No
Radiation treatment
*
Yes
No
Tendency to bleed
*
Yes
No
Diabetes
*
Yes
No
Heart problems
*
Yes
No
Psychiatric disorder
*
Yes
No
Overgrown scars
*
Yes
No
Hepatitis or HIV
*
Yes
No
Autoimmune condition
*
Yes
No
Oral herpes
*
Yes
No
Difficulty with wound healing
*
Yes
No
High Blood Pressure
*
Yes
No
Pacemaker/Defibrillator
*
Yes
No
Emotional Disorder
*
Yes
No
Keloid
*
Yes
No
Liver/Kidney disease
*
Yes
No
Any other medical condition(s) we should be aware of:
Submit
Should be Empty: