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New & Restart Patients
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PATIENT MEDICAL HISTORY
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How did you hear about us?
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First and last name of Patient that referred you
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Are you pregnant, trying to get pregnant and/or breastfeeding?
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When was your last visit with your Primary Care Doctor?
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For what concerns did you see your Primary Care Doctor?
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When did you last have bloodwork done?
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Were there any labs of concern in recent bloodwork? If so, which?
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Current or past history of illnesses or injuries?
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List past surgeries including the type, reason, and date
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Do you see any specialists?
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Do you have a history of substance abuse?
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Do you have high blood pressure?
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Do you have a history of any heart problems?
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Do you suffer from any of the following? Select all that apply
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Is there anything else we should know about your health history?
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Do you have any allergies to medications?
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List current medications and vitamins/supplements
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Describe previous weight loss efforts, if any
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Have you taken a prescription weight loss medication?
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If yes, which prescription appetite suppressant have you taken in the past?
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Which side effects have you experienced, if any?
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Include any other side effects not mentioned in the list
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Are you hungry all the time?
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Do you have any of the following? Select all that apply
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Do you drink alcohol?
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If so, how many alcoholic drinks do you have per week?
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How many oz of water do you drink daily?
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What other beverages do you drink?
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How many minutes do you exercise per week?
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Describe the type of exercise(s) you do
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Female Organ Problems - Self
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Female Organ Problems - Family
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Cancer - Self
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Cancer - Family
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Diabetes - Self
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Diabetes - Family
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Kidney Problems - Self
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Kidney Problems - Family
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Liver Problems - Self
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Elaborate on any "yes" answer for self and family history
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Formulario de Historia Médica del Paciente
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¿Cómo se enteró de nosotros?
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¿Cuántas veces han intentado perder peso antes?
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¿Tienes problemas para perder peso?
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¿Retiene el agua?
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Alergia a alguna droga?
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Ha tenido alguna operación?
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Razón/Tipo
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Fecha
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Otro
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¿Tiene alguna enfermedad grave o lesiones?
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Mencione los medicamentos que actualmente este tomando
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Historia de abuso de sustancia
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¿Has tomado medicamentos para bajar de peso antes?
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¿Cómo?
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¿Algún problema con su corazón o la presión arterial?
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¿Tiene alguno de los siguientes? Marque todas las que aplican
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¿Cuánta agua bebe al día?
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¿Fuma cigarillos?
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¿Cuántos al día?
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¿Tiene hambre todo el tiempo?
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Actividad
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¿Sufre usted de alguno de los siguientes? Marque todas las que aplican
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Familia e Historia Clínica
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Otras enfermedades importantes
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Mujeres
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¿Está Embarazada?
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¿Está Lactando?
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Dysport & Filler Good Faith Exam
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Allergies
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Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?
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Are you pregnant, trying to get pregnant or breastfeeding?
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Have you gotten neuromodulator(s) in the past? If so, which?
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Hypersensitivity to botulinum A toxin products?
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Hypersensitivity to lidocaine?
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Infection at proposed injection site(s)?
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Any bleeding disorders?
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Any swallowing problems?
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Any blurred vision and/or double vision?
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Allergy to human albumin/cow milk protein?
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History of herpes simplex?
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Do you have any of the following conditions?
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Amyotrophic lateral sclerosis (ALS)?
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Motor neuropathy?
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Myasthenia gravis (MG)?
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Multiple sclerosis (MS)?
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Eaton-Lambert Syndrome?
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Facial nerve palsy?
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PCA Skin/Microneedling Good Faith Exam
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About You:
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What is your hereditary background?
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Natural eye color:
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Natural hair color:
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What do you consider your skin?
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Describe your skin? (choose all that apply)
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What are the changes you'd most like to see in your skin?
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Lifestyle:
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Are you pregnant, trying to get pregnant or breastfeeding?
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Do you wear contact lenses?
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Do you currently have a sunburned / windburned / red face?
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Are you in the habit of going to tanning booths?
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Do you smoke or use tobacco?
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Do you participate in vigorous aerobic activity or sports? If so, what type?
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On average, how many hours per week do you spend outdoors?
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Medical/Treatment History:
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Do you currently use hair removal cream or wax?
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Have you had a chemical peel or any type of procedure with a medical device within the last 14 days?
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Do you have regular collagen, neuromodulator (Botox/Dysport) or other dermal filler injections?
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Have you ever undergone Accutane (isotretinoin) therapy?
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Do you develop cold sores/fever blisters?
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Are you allergic/sensitive to any of the following?
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Are you currently taking any medications, topical or otherwise?
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Have you ever used any other products that caused a bad reaction? (If so, please describe)
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Sculptra Good Faith Exam
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Are you pregnant, trying to get pregnant or breastfeeding?
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Hypersensitivity to any of the components of Sculptra?
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Hypersensitivity to lidocaine?
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Do you have severe allergies manifested by a history of anaphylaxis or history or presence of multiple severe allergies?
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Any history of or susceptibility to keloid formation or hypertrophic scarring?
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Do you currently have a sunburned / windburned / red face?
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Do you currently have any skin rashes, cold sores and/or sinus infections?
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Any dental work within the past 2 weeks?
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Are you in general good health?
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If no, please specify
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IV Therapy Good Faith Exam
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Allergies
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Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?
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Are you pregnant, trying to get pregnant or breastfeeding?
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Do you have any kidney disease?
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Do you have any liver disease?
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Do you have congestive heart failure?
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Do you have end stage renal disease?
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NAD+ Good Faith Exam
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Allergies
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Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?
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Are you pregnant, trying to get pregnant or breastfeeding?
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Do you have any cardiovascular disease, such as severe heart failure, multiple medicated hypertension or irregular heart rate?
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Do you have any personal history of cancer?
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If yes, please specify
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Do you have any significant family history and/or genetic predisposition for cancer?
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If yes, please specify
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Strawberry Laser Good Faith Exam
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Are you pregnant or breastfeeding?
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Do you have any kidney issues?
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If yes, please specify
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Do you have any liver issues?
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If yes, please specify
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Are you currently taking any medication that affects the skin?
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If yes, please specify
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Do you have any sores and/or lesions to the skin in the area(s) to be treated?
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If yes, please specify
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Do you have any skin conditions in the treatment area(s)?
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If yes, please specify
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