Health History Questionnaire Your privacy is important to us! Your personal information will not be shared with anyone outside of our organization for any reason. Patient Name (Full Name)*Email* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HeightWeightPlease describe any concerns you would like to discuss at your appointment.*Medications/Medical Treatment*Please list all Medication Allergies and Reactions.Do you take Aspirin or any blood thinners (Aleve/Ibuprofen/Fish oil) daily? If so, please describe.*YesNoDo you use Accutane or have you used Accutane within the last year?YesNoDo you currently use a Retin-A or Tretinoin?YesNoPlease list all medications you are currently taking including all herbal supplements.*Are you currently under the care of a physician for any condition? If yes, please describe.YesNoDo you have a history of any of the below conditions? If yes, please describe. Skin CancerYesNoHeart DiseaseYesNoHeart ArrhythmiaYesNoLung DiseaseYesNoThyroid DiseaseYesNoShortness of breath with stairsYesNoChest PainYesNoSleep ApneaYesNoDiabetesYesNoDifficulty Healing or ScarringYesNoHepatitis A/B/CYesNoHIVYesNoSeizure/StrokeYesNoPollen AllergiesYesNoDepression/Other Psychological DisordersYesNoLasik Eye SurgeryYesNoDry EyeYesNoPlease list and all previous surgeries with approximate dateHave you had any complications from anesthesia? If yes, please describe.YesNoSocial HistoryDo you smoke, vape, or use any form of nicotine? If yes, please describe.*YesNoDo you drink alcohol? If yes, how much?*YesNoDo you use illegal substances?*YesNoAre you currently pregnant or breastfeeding?YesNoCosmetic HistoryHave you had any non-surgical treatments (Botox, Fillers, Lasers, Peels)? If yes, please describe.YesNoDescribe your history of sun exposure.Are you interested in any non-surgical treatments? Dermal Fillers (Juvederm, Voluma, Volbella, Vollure, Restylane, Restylane Silk, Sculptra) Neuromodulators (Botox/Dysport) Laser Treatments (BroadBand Light/Photofacial, Halo) Chemical Peels Do you currently use a skincare regimen? If yes, please describeYesNoWould you like to be added to our email list to receive monthly special?YesNoBy submitting this form I agree to the Terms of Use *PhoneThis field is for validation purposes and should be left unchanged.
