PATIENT PROFILE & MEDICAL HISTORY Name

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PATIENT PROFILE & MEDICAL HISTORY
Name _____________________________ Birthday________________ Age ____
Address_________________________________ State______ Zip_____________
E-Mail Address______________________________________________ Sex M / F
Phone_____________________________________________________________
Home
Cell
Work
Primary Doctor____________________________________ Phone_____________
Emergency Contact___________________________________________________
Name
Phone
Relationship
------------------------------------------------------------------------------------------------------------Allergies Food & Medicine_____________________________________________
__________________________________________________________________
Current Medication___________________________________________________
___________________________________________________________________
Do you have any chronic, underlying health problems? Y / N _________________
___________________________________________________________________
Do you have any hormonal disorders? Y / N ______________________________
Are you pregnant or lactating? Y / N
Are your menstrual periods regular? Y / N
Do you have a history of keloid scaring? Y / N
Do you have a history of herpes I or II in the area to be treated? Y / N
Do you have any implants, tattoos, or permanent make-up? Y / N Please list:
___________________________________________________________________
Have you taken Accutane or Anticoagulants in the last 6 months? Y / N
Do you use any topical medications? Y / N Please list_______________________
Do you use tanning beds or self tanners? Y / N
Date of last sun/tanning bed exposure? __________________________________
Do you smoke? Y / N How long? _______________________________________
Do you have an internal pacemaker? Y / N
------------------------------------------------------------------------------------------------------------Please circle all that apply
Have you ever had a peel?
Yes
No
Date___________
Facial Surgery/Laser resurfacing?
Yes
No
Date___________
Botox Injections?
Yes
No
Date___________
Cosmetic Fillers?
Yes
No
Date___________
Leg Vein Treatments?
Yes
No
Date___________
___________________________________________________________________
How did you hear about us? ___________________________________________
___________________________________________________________________
Patient Signature ___________________________________ Date_____________
__________________________________________________ Date____________
Guardian if under 18
Relationship
I acknowledge that the above information to be true to the best of my knowledge
and understand that providing information that is less than accurate may result in
personal injury.
_________ Initial
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