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Are you in good health?
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Are you in good health?
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Are you pregnant?
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Are you pregnant?
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Have you had any serious illnesses within the last five (5) years?
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If so, please list.
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Have you been hospitalized within the last five (5) years?
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If so, please list.
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Have you ever had any prior cosmetic procedures or cosmetic surgery?
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If so, please list.
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Do you have or have a family history of the following health conditions?
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Have you had abnormal bleeding associated with previous surgery or trauma?
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If so, please list.
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Do you have any health conditions?
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Please select all that apply.
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If you have selected "other," please list.
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Do you have any food allergies?
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If so, please list.
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Are you taking any medications?
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Choose all that apply.
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If so, please list.
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Do you have any medication allergies?
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Please select all that apply.
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If you have selected "other," please list.
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Do you use any psychiatric medications?
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If so, please explain.
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Do you use chemical substances or drugs?
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If so, please explain.
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Do you bruise easily?
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If so, please explain.
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Have you ever needed a blood transfusion?
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If so, please explain.
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Do you smoke or use tobacco products?
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Please select the choice that best applies.
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Do you consume alcohol?
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Please select the choice that best applies.
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Do you have any condition not listed that the doctor and office should know about?
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