~ Medical Spa ~
General NEW Patient Information
Name: ______________________________________________________________
Today’s Date:_____________________
Date of Birth:_________________________
SS#:____________________________
Gender: ________________
Address: ________________________________________________________________________________________________
Home Phone: __________________________________
Cell Phone: _____________________________
E Mail: _________________________________________________
Referred by: ____________________________________
Emergency contact: _______________________________________
Relationship: ___________________________________
Reason for Consultation (Circle all that apply)
GROUPON Number:_____________
Acne / Acne scarring
Unwanted hair
Skin Laxity
Brown spots / sun damage
Pigmented lesions
Skin texture / scars
Spider veins
Rosacea
Flushing of the skin
Fine lines and wrinkles
Melasma
Crow’s feet
Dry skin
Large pores
Deep lines/shadows
Skin History
How long have you noticed this concern? _______________________________________________________________________
Do you feel that your condition is worsening?
Yes
No
Have you ever been treated for this?
Yes
No
If yes, please explain: ______________________________________________________________________________________
________________________________________________________________________________________________________
Are you currently taking medicine for any skin condition?
Yes
No
Are you currently taking or have you ever taken any of the following? (Circle all that apply)
Accutane
Retin-A
Hydroquinone or bleaching agent
Do you get cold sores or fever blisters?
Yes
No
Do you form thick or raised scars (keloid)?
Yes
No
Do you develop hyperpigmentation?
Yes
No
When were you last exposed to direct sun or a tanning booth? ___________________________________________________
Do you use self-tanning products?
Yes
No
Are you planning a vacation in the sun in the next 3 months?
Yes
No
Have you ever used any of the following hair removal methods in the past 6 weeks? (Circle all that apply)
Shaving Waxing Stringing
Tweezing
Depilatories
Have you ever had IPL or Laser hair removal?
Yes
No
Have you ever had skin resurfacing, rejuvenation or chemical peels?
Yes
No
Have you ever had treatment for pigmented lesions or sunspots?
Yes
No
Have you ever had skin acid peels?
Yes
No
Have you ever had MicroDermabrasion treatments?
Yes
No
Do you get facials?
Yes
No
Have you ever had Botox or Filler treatment?
Yes
No
What type of skin care products do you currently use?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Personal History
Do you smoke?
Yes
No
if yes ______ packs per day
Do you consume alcohol?
No
Rarely
Frequently
Do you exercise regularly?
Yes
No
Do you wear contact lenses?
Yes
No
Cosmetic History
List all injectibles such as Botox, Juvederm, Restylane, Radiesse, collagen, fat, or other.
Date
Area
Any adverse reactions:
1. _____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
Are you interested in any cosmetic procedures?
Yes
No
If Yes, What procedure?__________________________
Medical History
Are you currently under the care of a physician?
Yes
No
If yes, for what:___________________________________________________________________________________________
Do you have any of the following conditions?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Arthritis
Any active infection
Bleeding disorders
Bruising
Dark spots of pregnancy
Diabetes
Cancer
o
o
o
o
o
o
o
Chest Pain
Epilepsy or seizures
Heart disease
Hepatitis
Herpes simplex
High blood pressure
Hormone imbalance
HIV / AIDS
Neurologic disorders
Sensitive teeth
Skin cancer or moles
Skin injury
Vision deficits
Thyroid disease
Other___________________________________
Do you have allergies to any of the following? (Circle all that apply)
Eggs
Latex
Food
Plants
Peanuts Anesthesia
Medications allergies: ______________________________________________________________________________
Do you take any of the following? (Circle all that apply)
Accutane
Appetite suppressants
Insulin
Antibiotics
Aspirin or Ibuprofen
Sedatives
Blood thinners
Cortisone or steroids
Thyroid medication
Anti-depressants
Hormone/contraceptives
Other___________________________________________________________________________________________
Are you taking herbal preparations or vitamins? (St. John’s Wort, Vitamin E) Yes No
List: ____________________________________________________________________________________________
List all surgeries:
Date
Procedure
Surgeon
1. ______________________________________________________________________________________________
2. ______________________________________________________________________________________________
3. ______________________________________________________________________________________________
Do you have any issues with bruising or bleeding?
Yes
No
Do you exercise regularly?
Yes
No
Have you ever had an issue with your nerves or muscles? (Strokes, temporary paralysis, Bell’s palsy, nerve injuries, etc.)
Yes
No
If yes, describe _____________________________________________________________________________
Do you need to take antibiotics before procedures such as dental?
Yes
No
Do you suffer from any neurological disorders? (Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic, Lateral
Sclerosis (ALS).
Yes
No
Do you have a pacemaker or other implantable device?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you taking birth control pills?
Yes
No
Do you have regular periods?
Yes
No
For female patients only:
I have answered the questions contained in this questionnaire to the best of my knowledge. I understand that it is my
responsibility to inform my practitioner of my current health conditions while seeking treatment as a patient. I will update
this information as it occurs or if there are any changes to my health in between treatments
Signature: _________________________________________ Date: ___________________