MEDICAL HISTORY
This is a confidential part of your treatment and will be kept in this office. Information included on this form will not be
released to anyone without written authorization from you.
DATE:_____________________
NAME:_________________________________________________________
(Last)
DOB: _____________________
Is your general health good now?
(First)
(Mi)
BIRTHPLACE:_________________ Years in NM:____________________
Y
N
Date of your last physical exam:__________________________
Name of Primary Care Physician_____________________________________________________________________
PERSONAL HISTORY OF ILLNESS
(circle all that apply)
Acne
Acid Reflux (GERD)
AIDS/HIV
Allergies
Alopecia
Alzheimer’s Disease
Anemia
Anxiety
Arthritis
Asthma
Bleeding Disorders ____________________________
Blood Clots (DVT)
Cancer Type: _________________________________
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Crohn’s
Dental Complications Type: _____________________ Depression
Diabetes Mellitus
Diverticulitis
Eczema
Emphysema
Epilepsy
Glaucoma
Gout
Hayfever
Headaches
Heart Disease
Hepatitis Type: _______________________________
Hives
Hypercholesterolemia
Hyperlipidemia
Hypertension
Hyperthyroidism
Hypothyroidism
Impetigo
Irritable Bowel Syndrome (IBS)
Leukemia
Lymphoma Type: _____________________________
Measles
Melanoma
Migraines
Parkinson’s Disease
Psoriasis
Scarlet Fever
Seizures
Skin Diseases Type: __________________________
Sinus Problems
Sleep Apnea
Use of CPAP device?
Y
N
Stroke (TIA)
Syphilis
Tuberculosis
Ulcerative Colitis
Ulcers Where? __________________________
Varicella Zoster (Chicken Pox/Shingles)
Vertigo
Vitiligo
Warts Sites Involved? ____________________
Are you currently pregnant?
Y
N
Date of last pregnancy:___________________________________________
Are you currently under the care of a psychiatrist?
Y
N
If so, who is the doctor? ____________________________
SOCIAL HISTORY
Do you smoke tobacco products? Y
Do you drink alcoholic beverages?
N
Y
If yes, what kind and how much? __________________________________
N
If yes, what kind, how much and how often?__________________________
PAST SURGERIES (What kind and date):
______________________________________________________________________________________________________
PLEASE LIST ALL CURRENT MEDICATIONS (INCLUDING NON-PRESCRIPTION MEDICATIONS)
______________________________________________________________________________________________________
_____________________________________________________________________________________________________
PLEASE LIST ANY DRUG ALLERGIES
_____________________________________________________________________________________________________
FAMILY HISTORY OF ILLNESSES
Has anyone in your immediate family ever had?
High Blood Pressure ________ Diabetes ________ Cancer ___________ Melanoma ____________ Asthma _________
Nervous disorders __________ Eczema _________ Psoriasis _________ Seizures/epilepsy __________ Acne _________
Hayfever_________
Skin Cancer _______________ Other, please explain: _____________________________________
Health issues that interest you (please check all that apply)
_______ Botox Cosmetic
_______ A.H.A. and Glycolic Peels
_______ Skin care advice
_______ Juvéderm, Restylane or Collagen Fillers
_______ Prevage MD
_______ Skin care products
_______ Skin rejuvenation
_______ Hyperpigmentation
_______ Age spots
_______ Avage, Retin-A or Tazorac
_______ Microdermabrasion
_______ Sunscreen advice
_______ Chemical Peels
_______ Removing leg veins
_______ Hair removal
_______ Eyebrow enhancement
_______ Spider vein treatment
_______ Laser treatments
_______ Eliminating underarm sweating
_______ Removing facial veins
_______ Latisse
_______ Other _________________________________________________________
Would you like to be contacted regarding cosmetic specials?
Y
N
Email: ___________________________________