Client Intake Form

Patient information as of today's date: (If information is not available, please put N/A)
Patient information as of todays date

MonthDayYear
Date
Patient Name
DOB
Address
Apt#
City
State
Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Occupation
Employer
Preferred Language
Sex
Emergency Contact Name:
Emergency Contact Phone Number
Reason for your visit today
Date of last physical

MonthDayYear
Date
Name of Primary Physician
How is your general health
List all and any allergies:
Please include seasonal, topical and drug allergies.
List all medications you are taking (prescription and OTC)
Do you take Asprin, Advil, Motrin, Ibuprofen or any anti-inflammatory medication more than once per week? If yes, please explain.
Do you smoke? If yes, how much and for how long?
Do you drink alcohol? If yes, how much/ how often?
Do you regularly use a tanning bed or sun exposure? If yes,how much/how often?
Do you regularly take vitamins? If yes, what kind and how often?
Are you currently pregnant, breastfeeding, or are you currently trying to become pregnant?
Have you ever had any of the following:

AsthmaArthritisAnemiaAutoimmune disorderBlood disorderChest PainChronic diarrheaClotting disorderColon problemsDiabetesDepressionEasily bruiseExcessive scarringExcessive bleedingHeart attackHeart valve diseaseHeart valve replacementHeart failureHigh/low blood pressureHepatitisHIVIrregular heart beatIntestinal problemsKeloidsKidney diseaseLiver diseaseLung diseaseMultiple SclerosisMuscular DystrophyMVPMigrainesRheumatic feverShortness of breathSeizuresStomach problemsVaricose veinsUnusual moleTattoo/ permanent makeupStrokeThyroid disorder
Have you ever been diagnosed with Cancer? If yes, please list type
Do you have a pacemaker, insulin pump, LVAD, defibrillator, metal plates, or any other device implants in the body?
Do you have an impaired immune system?
Have you been on Accutane or Isotretinoin in the last 12 months?
Have you ever had injections of filler or neurotoxins such as Botox? If yes, when was your last injection?
Do you have Herpes Simplex or the mouth/face or do you ever get cold sores or fever blisters?
Do you use retinol, tretinoin, or any prescription skincare?
When did you last get a facial or exfoliate your skin at home?
When was your last laser treatment?
When did you last wax or use and depilatory product?
Please list all surgeries with dates:
Please list any cosmetic procedures you have had (surgical and non-surgical) with dates:
Please describe your current skin care process:
Please list any substances that irritate your skin:
Please list any concerns that you have:
Please list and treatments or products that interest you:
To the best of my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential. All efforts are routinely made to ensure privacy is upheld.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty: