Aesthetic Health Information Questionnaire

    What's your name?








    Your Address (optional)













    Health History

    Medication



    Surgeries/Dates




    YesNo


    Allergies



    Have a history of?


    Heart diseaseExcessive bleeding, circulating problemsDiabetesKeloid scarringSeizuresFaintingThyroid problemsCold sores, herpesLiver diseaseHigh blood pressureAuto-immune diseaseMigrainesCancerOther



    PregnantNursingMenstrual problemsOther (please specify)



    SmokeDrink alcoholOther



    DailyWeeklyMonthlyOccasionallyNever


    What medical aesthetics procedures are you interested in?



    Rein-a RenovaPrescription acne medicationAny retinoic acidBirth control pills/patchAccutaneSteroidsOther (please specify)



    BotoxDermal fillersLaser treatmentsTattooMicrodermabrasionChemical peelPermanent make upImplants/Piercing


    Tanning


    YesNoif yes, when



    YesNo



    YesNo




    The above information is true and accurate to the best of my knowledge
    I have read and agreed to Terms and Conditions


    Patient Signature