Patient History Form: Please
Circle All That Apply.
| Do You Have A History Of: |
YES |
NO |
| Heart Disease |
Y |
N |
| High Blood Pressure |
Y |
N |
| Pace Maker |
Y |
N |
| Prosthetic Heart Valve |
Y |
N |
| Bleeding Problems |
Y |
N |
| Thyroid Disorder |
Y |
N |
| Diabetes |
Y |
N |
| Anemia/Blood Disorder |
Y |
N |
| Poor Wound Healing |
Y |
N |
| Pigmentation Problems |
Y |
N |
| Keloids/Abnormal Scars |
Y |
N |
| Radiation Treatment |
Y |
N |
| Skin Cancer |
Y |
N |
| Other Cancer |
Y |
N |
| Other Medical Problems |
Y |
N |
| Tobacco Use |
Y |
N |
How long quit? _______________
How long smoked? ____________
(Please Specify Other Problems):
______________________________________
______________________________________
| Are You Pregnant? |
Y |
N |
| Are You Breastfeeding? |
Y |
N |
Please Specify Anything Else We Should Know About Your History:
______________________________________
______________________________________
______________________________________
______________________________________
Please indicate which of the following concerns
you have about your skin:
Aged Skin |
Hair Removal |
Pigmentation |
Loose Skin |
Rosacea |
Spider Veins |
Sun Damage |
Large Pores |
Lines |
Scars |
Acne/Scars |
Stretch Marks |
| Fat |
Vessels |
LipoDissolve |
Wrinkles |
Sun Damage |
Other:_______ |
|
| Medication Allergies: |
YES |
NO |
| Lidocaine |
Y |
N |
| Novacaine |
Y |
N |
| Antibiotics |
Y |
N |
(Please Specify Allergies):
______________________________________
______________________________________
| Current Medications: |
YES |
NO |
| Aspirin |
Y |
N |
| Blood Thinner |
Y |
N |
| Heart Medication |
Y |
N |
| Insulin |
Y |
N |
| Birth Control |
Y |
N |
| Hormones |
Y |
N |
(Please Specify Other Meds):
______________________________________
______________________________________
Please indicate a service you are interested in
or would like more information on:
Laser Skin Rejuvenation |
Hydroxy Acid Peels |
Laser Hair Removal |
Spider Vein Treatment |
IPL Pigment Treatment |
LipoDissolve |
Age Spot Treatments |
Rosacea Treatment |
Wrinkle Laser Treatment |
Redness/Vessels |
Acne Laser Treatment |
Freckle Treatment |
Portrait PSR |
Microdermabrasion |
| TITAN Skin Tightening |
Botox® |
Stretch Mark Treatments |
Sun Damage Repair |
Tatoo Removal |
Other____________ |
How did you hear about our office?
________________________________________
Friend, Phone Book, Internet, Newspaper, Radio |
|