Integrity Medical Aesthetics LLC
Aesthetic Health Information Questionnaire
Name:_____________________________ Age: __________ DOB:______________________
Date:__________________ Address:______________________________________________
City:__________________________________ State:___________ Zip:___________________
Phone Home:__________________ Cell:__________________ Work:___________________
Email:_______________________________________________________________________
Emergency Contact:_____________________________ Phone:_________________________
How did you hear about us?_____________________________________________________
Health History
Medication (Prescription & over the counter supplements):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Surgeries/Dates (Cosmetic & medical)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies (Latex, iodine, food etc.):________________________________________________
Do you have an allergy to Lidocaine:
Yes____________ No______________
Have a history of? (Check all that apply)
o Heart Disease
o Cold Sores, Herpes
o Excessive Bleeding, Circulating
problems
o Liver Disease
o Diabetes
o High Blood Pressure
o Keloid Scarring
o Auto-Immune Disease
o Seizures
o Migraines
o
o
o
o
Fainting
Cancer
Thyroid problems
Other
Integrity Medical Aesthetics LLC. Medical Questionnaire
(Continued)
Are you? Pregnant_________ Nursing_____________
Menstrual problems____________
Do you? Smoke ___________ Drink Alcohol _____________ Amount per day ______________
WHAT MEDICAL AESTHETICS PROCEDURES ARE YOU INTERESTED IN? ( Check all that apply)
o
o
o
o
o
o
Botox
Dermal Fillers (Juvederm XC, Radiesse)
Facial Vessels/Rosaecea
Sun/Age Spots
Laser Scar Resurfacing
Laser Skin Resurfacing
o
o
o
o
o
o
Spider Vein Treatments (Legs)
IPL Photo Rejuvenation
Laser Hair Removal
Mona Lisa Touch Laser
Acne/ Acne Scars
Melasma
Have you ever had/Currently using:
o Retin-A Renova
o Any retinoic acid
o Accutane
o Prescription acne medication
o Birth Control Pills/Patch
o Steroids
Previous Cosmetic Facial Treatments:
o
o
o
o
o
o
o
o
Botox
Dermal Fillers
Laser Treatments
Tattoo
Tanning (Last 2 weeks):
Yes
Microdermabrasion
Chemical Peel
Permanent Make Up
Implants/Piercing
Date:_________
Are you concerned about thinning eyebrows/ eyelashes?
Are you using Latisse? Yes
No
Yes
No
No
What skin products are you’re currently using?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The above information is true and accurate to the best of my knowledge
Patient Signature____________________________________________Date_______________