MEDICAL HISTORY FORM Home | Patients | Medical History Form Medical History Form Step 1 of 2 50% DemographicsName First Name Last Name Birthdate MM slash DD slash YYYY Today's Date MM slash DD slash YYYY How did you hear about us?ReferralGoogle/other internet searchFacebookInstagramSnapchatOtherAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Primary PhoneOther PhonePreferred Contact Method Email Primary Phone Other Phone Is it important to be discreet? Yes No Gender Female Male Marital Status Emergency Contact PhoneRelationship Describe the nature of your visit.Medical HistoryHeight Current Weight Highest Weight Primary Care Physician Address PhoneDo you have or have you experienced any of the following conditions (check all that apply)? Heart attack Rheumatic fever Heart murmur High blood pressure Heart condition Varicose veins Arthritis or rheumatoid Diabetes Contact lenses Hearing aid Bleeding disorder High cholesterol Dizziness or fainting Epilepsy or seizures Stroke Immune disorders Anxiety Anemia Hepatitis, liver, or kidney disease Dental appliances Blood transfusion Blood clot Pregnant or lactating Thyroid problems Pneumonia Respiratory disease Asthma Disabilities Gall bladder problems HIV Sleep apnea or snoring Acid reflux Cold sore Cancer Please describe any conditions indicated above.Please indicate any other medical conditions not listed.Medications, Dosage and FrequencyPlease list all medications. Add rows as needed.MedicationDosageFrequency Please list all medications. Add rows as needed.Please list ALL vitamins, herbs, supplements or holistic treatmentsHave you taken Accutane in the past six months? Yes No Do you have problems getting numb at the dentist? Yes No Family HistoryHave any parents, grandparents, or siblings had any of the following conditions (check all that apply)? Abnormal bleeding Cancer Heart disease or stroke Diabetes Anesthetic problems Kidney disease Liver disease Malignant hyperthermia Sudden death AllergiesDo you have allergies to any of the following? Medication Food Latex Tape None Please list all allergies. Add rows as needed.AllergyReaction Please list all allergies. Add rows as needed. Surgical HistoryPlease list all surgeries. Add rows as needed.SurgeryDate Please list all surgeries. Add rows as needed.Any history of complications or bad result? Yes No If yes, please explain.List history of anesthesia, complications, or reactions. Include local, general, spinal or epidural.Female Patients OnlyNumber of PregnanciesNumber of ChildrenDid you breastfeed? If yes, for how long? Do you have a menstrual cycle? If no, why? If yes, date of last menstrual cycle? MM slash DD slash YYYY Social HistoryHave you used any of the following? Check all that apply. Tobacco Alcohol Recreational drugs Caffeine If yes, please explain.SubstanceAmountNumber of years Add rows as needed.Do you exercise? If so, how often and for how long? Skin BackgroundHave you had prolonged sun exposure in the past 3 days? Yes No If so, are you currently sunburned? Do you use tanning beds? Yes No Are you using chemical tanning solutions or creams? Yes No Do you use sunscreen on a regular basis? Yes No Do you experience acne? Yes No If so, how often? Frequently Occasionally Rarely Do you experience cystic breakouts? Yes No If so, do you have scarring as a result? Yes No Do you use any of the following? Check all that apply. Retin-A Glycolic acid Lactic acid Hydroquinone Explain your current skin care regimen and list the products used.Skin type (check all that apply) Caucasian Hispanic Mediterranean African American American Indian Asian Other Untitled Have you had any of the following in the past 6 months? Check all that apply. BOTOX™ DYSPORT™ XEOMIN™ Dermal-filler injections None If yes, please indicate approximate dates. Are you interested in other services?Check all that appy.Untitled Liposuction/Vaser Lipo/Lipo 360° Tummy Tuck/Abdominoplasty Brachioplasty (Arm Lift) Breast Augmentation BBL (Brazilian Butt Lift) Fat Transfer Thigh Lift Mini Face Lift Brow Lift Back Lift Hormone Replacement Laser Hair Removal Laser Vein Removal Sclerotherapy Pigmented Lesion Removal (unwanted brown spots) Mole Removal Ear Lobe Repair Non-Ablative Laser Facial (facial rejuvenation, acne, rosacea, redness, fine lines and wrinkles) BOTOX™, DYSPORT™, XEOMIN™ Facial Fillers (lips, facial lines and wrinkles) Laser Resurfacing (facial lines, wrinkles, acne scars and facial rejuvenation) Microdermabrasion, Chemical Peels Laser Acne Treatments Anti-Aging Skin Care and Makeup Living WillDo you have a living will? Yes No If no, would you like information regarding one? Yes No DNRAre you a DNR (Do Not Resuscitate) patient? Yes No I certify that the above medical history is accurate and correct to the best of my knowledge.Type Name Relationship to patient if minor Date MM slash DD slash YYYY Δ
