Aesthetics Medical History Form

First Name

Last Name

Date of Birth

Prefered Name / Nickname

Patient Gender

Phone no.

Marital Status

Married

Unmarried

Divorced

Widowed

Emergency Contact

Phone no.

Disability ?

Yes

Date of disability

GP Practice

Where is your primary care doctor located ?

Phone Number of primary care doctor:

allergic to any medications

Yes

allergic to any medications

Do you smoke?

Yes

How many years did you smoke?

If you quit, when did you stop?

Do you drink alcohol?

Personal opinion

Medical History

Skin Concerns - Please check all that apply.

Questions

Please answer the following questions:

Do you have any current or chronic medical illnesses?

Yes

Your chronic medical illnesses list here

Do you have any current or chronic skin conditions?

Yes

chronic skin conditions details

Do you have any allergies to medications, foods, latex or other substances?

Yes

Your allergies to medications, foods, latex or other substances details

Do you get facials, chemical peels or microdermabrasions regularly?

Yes

Details of facials, chemical peels or microdermabrasions regularly

Are you on any form of birth control?

Yes

Birth control medication details

Are you pregnant, currently trying to become pregnant, or breastfeeding?

Yes

Are you pregnant, currently trying to become pregnant, or breastfeeding? Please Explain:

Are menstrual periods regular, or have you ever been diagnosed with Polycystic Ovarian Disorder?

Yes

Are menstrual periods regular, or have you ever been diagnosed with Polycystic Ovarian Disorder? Details here:

Are you currently under a doctor’s care?

Yes

Are you currently under a doctor’s care? Details here:

Do you take/use any medications, vitamins or supplements on a regular basis?

Yes

Do you take/use any medications, vitamins or supplements on a regular basis? Details:

Are there any topical products that you use on your skin on a regular basis?

Yes

Are there any topical products that you use on your skin on a regular basis? Details:

Do you have any unusual reactions or problems with topical anesthesia creams?

Yes

Do you have any unusual reactions or problems with topical anesthesia creams? Details:

Do you have any sexually transmitted diseases?

Yes

Do you have any sexually transmitted diseases? Details:

In the last six (6) months, have you used any of the following:

Anticoagulants or blood thinning medications

Photosynthesizing medications

Anti-inflammatory medications

Date:

In the last (1) month, have you used any of the following products:

Glycolic acid or other alphahydroxy or betahydroxyl acid products or chemical peels?

Exfoliating or resurfacing products or facial treatments?

Date:

Do you have or have you ever had any permanent makeup, tattoos, implants or fillers, including but not limited to, collagen, autologous fat, Restylane, etc?

Yes

Do you have or have you ever had any permanent makeup, tattoos, implants or fillers, including but not limited to, collagen, autologous fat, Restylane, etc? Details:

Have you taken Accutane (or products containing Isotretinoin) in the last 12 months?

Yes

Have you taken Accutane (or products containing Isotretinoin) in the last 12 months? Details:

Yes & No Questions

Please answer yes or no for the following:

Checkbox Grid

	Yes	No
Do you smoke?
Do you consume alcohol?
Do you exercise regularly?
Do you take/use any systemic/oral steroids?
Do you have a history of herpes I or II in the area to be treated (cold sores or blisters)?
Do you have a history of keloid scarring or hypertrophic scar formation?
Do you have a history of light induced seizures?
Do you have open scars or lesions?
Do you have history of radiation therapy in the area to be treated?
Have your taken tretinoin or used (like Retin-A, Renova) in the last six months?
Have you ever had a problem, when having your blood drawn?
Do you think you sweat more than normal or are you an excessive sweater?
Do you have a history of fainting passing out?
Do you consider yourself to have an anxious or nervous personality?
Have you ever been diagnosed with anxiety disorder?
Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last two weeks?