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Please Answer All Questions:
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Reason for todays visit
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Other reason for todays visit:
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Current Medications
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Current Medications (prescription & OTC):
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Current Topical Medications:
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Have you ever taken steroids?
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If yes, when was the most recent course?
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Have you ever taken Accutane?
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If yes, when?
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Have you ever taken herbal medications?
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If yes, which ones?
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Have you ever taken female hormones?
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If yes, which ones?
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Current Skin Care Regimen?
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Do you use a topical retinoid?
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Allergies:
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Have you had peels in the past?
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if yes (chemical peels)
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Peel Complications:
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Peel complications
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Have you had neurotoxins (Botox/Dysport) before?
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If Yes, Select Neurotoxins:
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Neurotoxin Complications:
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If Yes, Neurotoxin Complication Details
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Have you had fillers in the past?
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Select previous fillers
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Filler Complications:
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If Yes, Filler Complications
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Has patient had laser treatment in the past?
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If Yes, laser treatments:
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Laser Complications?
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If Yes, Laser complications.
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Surgical:
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Previous Surgical Procedures:
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If yes, select all that apply:
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List other surgical procedures below:
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Surgical complications?
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If yes, surgical complications.
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Are you currently pregnant?
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Are you currently nursing?
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History of the following medical conditions?
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Heart Disease
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if yes, please describe:
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Heart Murmur
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if yes, please describe:
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High Blood Pressure
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if yes, please describe:
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Pacemaker/Defibrillator
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if yes, please describe:
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Artificial Heart Valves
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if yes, please describe:
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Lung Disease
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if yes, please describe:
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Gastrointestinal disease
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if yes, please describe:
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Liver Disease
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if yes, please describe:
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Kidney Disease
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if yes, please describe:
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Seizures/Epilepsy
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if yes, please describe:
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Fainting Spells
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if yes, please describe:
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Stroke
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if yes, please describe:
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Eaton Lambert Syndrome
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if yes, please describe:
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Myasthenia Gravis
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if yes, please describe:
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Other Neuromuscular Disorders
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if yes, please describe:
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Bleeding Disorders
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if yes, please describe:
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Blood Clots
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When / Cause?:
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Have you had any of the following infections?
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Thryoid Disease
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if yes, what type?
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Diabetes
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Type 1 or 2?
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Multiple Sclerosis
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if yes, please describe:
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Autoimmune Disorders
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if yes, please describe:
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Arthritis
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Artifical Joints
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Other artificial joints:
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Double Jointed
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Problems with Anesthesia
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if yes, please describe:
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Emotional Disorders
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if yes, please describe:
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Skin Diseases
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If yes, Skin Disease:
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Skin Cancer
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if yes, Skin Cancer
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Keloids/Raised Scars
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Have you ever had ultraviolet light treatment?
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Have you ever had radiation treatment?
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Organ Transplant
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if yes, Which Organ
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Cancer (other than skin)
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if yes, Cancer
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Physician Comments:
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Past Surgeries:
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Other Medical Problems:
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Past Hospitalizations:
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Social History
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Do you drink Alcohol?
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Drinks per day / how many days a week? (average)
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Do you smoke?
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Packs per day / Years smoking
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Do you use sunscreen daily?
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What SPF / How many times do you reapply daily?
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Do you currently use tanning booths?
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Have you used tanning booths in the past?
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Exercise: Days per week?
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