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*

    Height

    Weight

    Please 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.*

    Do you use Accutane or have you used Accutane within the last year?

    Do you currently use a Retin-A or Tretinoin?

    Please 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.

    Do you have a history of any of the below conditions? If yes, please describe.
    Skin Cancer

    Heart Disease

    Heart Arrhythmia

    Lung Disease

    Thyroid Disease

    Shortness of breath with stairs

    Chest Pain

    Sleep Apnea

    Diabetes

    Difficulty Healing or Scarring

    Hepatitis A/B/C

    HIV

    Seizure/Stroke

    Pollen Allergies

    Depression/Other Psychological Disorders

    Lasik Eye Surgery

    Dry Eye

    Please list and all previous surgeries with approximate date

    Have you had any complications from anesthesia? If yes, please describe.

    Social History

    Do you smoke, vape, or use any form of nicotine? If yes, please describe.*

    Do you drink alcohol? If yes, how much?*

    Do you use illegal substances?*

    Are you currently pregnant or breastfeeding?

    Cosmetic History

    Have you had any non-surgical treatments (Botox, Fillers, Lasers, Peels)? If yes, please describe.

    Describe your history of sun exposure.

    Are you interested in any non-surgical treatments?

    Do you currently use a skincare regimen? If yes, please describe

    Would you like to be added to our email list to receive a monthly special?

    By submitting this form I agree to the Terms of Use*