General NEW Patient Information

~ Medical Spa ~

Name: ______Today’s Date:______Date of Birth:______Gender: ______SS#:______Address: ______Home Phone: ______Cell Phone: ______E Mail: ______Referred by: ______Emergency contact: ______Relationship: ______

Reason for Consultation (Circle all that apply) GROUPON Number:______Acne / Acne scarring Unwanted hair Skin Laxity Brown spots / sun damage Pigmented lesions Skin texture / scars Spider veins Rosacea Flushing of the skin Fine lines and wrinkles Melasma Crow’s feet Dry skin Large pores Deep lines/shadows

Skin History How long have you noticed this concern? ______Do you feel that your condition is worsening? Yes No Have you ever been treated for this? Yes No If yes, please explain: ______

Are you currently taking medicine for any skin condition? Yes No Are you currently taking or have you ever taken any of the following? (Circle all that apply) Accutane Retin-A Hydroquinone or bleaching agent Do you get cold sores or fever blisters? Yes No Do you form thick or raised scars (keloid)? Yes No Do you develop hyperpigmentation? Yes No When were you last exposed to direct sun or a tanning booth? ______Do you use self-tanning products? Yes No Are you planning a vacation in the sun in the next 3 months? Yes No Have you ever used any of the following hair removal methods in the past 6 weeks? (Circle all that apply) Shaving Waxing Stringing Tweezing Depilatories Have you ever had IPL or Laser hair removal? Yes No Have you ever had skin resurfacing, rejuvenation or chemical peels? Yes No Have you ever had treatment for pigmented lesions or sunspots? Yes No Have you ever had skin acid peels? Yes No Have you ever had MicroDermabrasion treatments? Yes No Do you get facials? Yes No Have you ever had Botox or Filler treatment? Yes No What type of skin care products do you currently use? ______

Personal History Do you smoke? Yes No if yes ______packs per day Do you consume alcohol? No Rarely Frequently Do you exercise regularly? Yes No Do you wear contact lenses? Yes No

Cosmetic History List all injectibles such as Botox, Juvederm, Restylane, Radiesse, collagen, fat, or other. Date Area Any adverse reactions: 1. ______2. ______Are you interested in any cosmetic procedures? Yes No If Yes, What procedure?______

Medical History Are you currently under the care of a physician? Yes No If yes, for what:______Do you have any of the following conditions? o Arthritis o Chest Pain o HIV / AIDS o Any active infection o Epilepsy or seizures o Neurologic disorders o Bleeding disorders o Heart disease o Sensitive teeth o Bruising o Hepatitis o Skin cancer or moles o Dark spots of pregnancy o Herpes simplex o Skin injury o Diabetes o High blood pressure o Vision deficits o Cancer o Hormone imbalance o Thyroid disease

Other______Do you have allergies to any of the following? (Circle all that apply) Eggs Latex Food Plants Peanuts Anesthesia Medications allergies: ______Do you take any of the following? (Circle all that apply) Accutane Anti-depressants Cortisone or steroids Antibiotics Appetite suppressants Hormone/contraceptives Blood thinners Aspirin or Ibuprofen Insulin Sedatives Thyroid medication Other______Are you taking herbal preparations or vitamins? (St. John’s Wort, Vitamin E) Yes No List: ______

List all surgeries: Date Procedure Surgeon 1. ______2. ______3. ______Do you have any issues with bruising or bleeding? Yes No Do you exercise regularly? Yes No Have you ever had an issue with your nerves or muscles? (Strokes, temporary paralysis, Bell’s palsy, nerve injuries, etc.) Yes No If yes, describe ______Do you need to take antibiotics before procedures such as dental? Yes No Do you suffer from any neurological disorders? (Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic, Lateral Sclerosis (ALS). Yes No Do you have a pacemaker or other implantable device? Yes No

For female patients only: Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you taking birth control pills? Yes No Do you have regular periods? Yes No

I have answered the questions contained in this questionnaire to the best of my knowledge. I understand that it is my responsibility to inform my practitioner of my current health conditions while seeking treatment as a patient. I will update this information as it occurs or if there are any changes to my health in between treatments

Signature: ______Date: ______