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Medical History
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Medical History (Please select all that apply)
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Frequent or occasional cold sores to mouth or genitalia?
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Do you wear contact lenses?
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Other, please specify:
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Details:
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Allergies and Medications
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Allergies and Medications (Please select all that apply)
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Other, please specify:
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Please provide further details as to the medication or reaction you experience:
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Current Medications (Including Prescription, Herbal, and Over the Counter)
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Pharmacy Name
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Tel #
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Fax
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Cross Streets
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Past Surgeries / Hospitalization with Date
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Patient Skin History
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Patient Skin History (Please select all that apply)
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Patient UV Exposure
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Patient UV Exposure (Please select all that apply)
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Patient Tanning History / Fitzpatrick Scale
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Patient Tanning History / Fitzpatrick Scale
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Patient Family History
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Patient Family History (Please select all that apply)
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Other, please specify:
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Details:
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Patient Social History - Alcohol, Drug Use, and Smoking
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Patient Social History
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Previous Aesthetic Procedures (Please check all that apply)
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Have you ever had Botox® or Dysport® injections?
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Last treatment date:
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Area treated:
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Have you had previous derma filler, Kybella®, or Sculptura® injections?
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Last treatment date:
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Area treated:
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Have you ever had threads (PDO/ PLLA)?
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Last treatment date:
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Area treated:
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Have you ever had chemical peel?
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Last treatment date:
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Area treated:
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Have you ever had microdermabrasion?
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Last treatment date:
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Area treated:
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Have you ever had any laser or photofacial treatments in the past?
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Last treatment date:
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Area treated:
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Do you have hyperpigmentation or hypopigmentation, keloid scars or marks/scars from physical trauma, chicken pox or acne?
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If yes, please describe:
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For Women Only
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Could you be pregnant?
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Are you breastfeeding?
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Are your menstrual cycles normal?
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Birth control pills?
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Depo-Provera?
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Date of late shot?
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Hormone replacement therapy?
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Periodic acne flare-ups related to cycle?
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Are there any other treatments/ conditions you are interested in hearing about?
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If yes, please select all that apply:
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Other, please specify:
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