Client Medical History Assessment

Client Medical History Assessment

In order to provide you with the most appropriate treatment we need you to complete thefollowing questionnaire. ALL information is strictly confidential.
Client Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Client Gender*
Client Birth Date*

MonthDayYear
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number*

Area CodePhone Number
Client Occupation*
Client E-Mail*
May we contact you via:

Note: We will not send spam or share your email with any other party.
Mail*

YesNo
Email*

YesNo
Telephone*

YesNo
Emergency Contact*
Phone Number*

Area CodePhone Number
How did you hear of us?*
Patient Medical History
Health issues and procedures/ products of interest to you (Please check all that apply)*

Aesthetic Treatments: Chemical Peels /Microdermabrasion / FacialsBOTOX Cosmetic TM (Botulinum Toxin Type A)Dermal FillersAge/Sun SpotsAcne ScarsActive AcneUneven Skin PigmentationFacial / Neck/ Chest RednessBirthmarksTattoo Removal / ReductionRosaceaHormone ManagementUrinary LeakagePainful IntercourseVaginal DrynessSkin RejuvenationSkin Care Products and Sunscreen AdviceUnwanted Hair ReductionSpider Vein TreatmentWrinkles / Facial LinesRough SkinLoose/ Sagging SkinOther
Cosmetic/Aesthetic History:
1) How would you describe your skin?*

SensitiveResilientNot sure
2) Describe your skin type:*

Oily, Large PoresOilyCombination Oily/DryDryVery Dry
3) Have you ever had any facial surgery preformed?*

NoYes
If "yes", what type?
4) Have you ever had any type of Aesthetic Procedure?*

NoYes
If "yes", what type?
5) Have you ever had any complications with any aesthetic procedures/treatments in the past?*

NoYes
If "yes", what?
6) Have you ever had any of the following injectable procedures done?*

BOTOXXeominJuvedermRadiesseBeloteroOther
Medical and Family History:
1) Are you currently under the care of a physician?*

NoYes
If "yes", for what?
2) Are you currently under the care of a dermatologist?*

NoYes
If "yes" for what?
3) Do you have any of the following medical conditions? (Please check all that apply):*

CancerHerpesHIV/AidsSeizure DisorderThyroid ImbalanceDiabetesArthritisSkin Disease/ Skin LesionsHepatitisAcneHigh Blood PressureHistory of Cold SoresSkin CancerHormone ImbalanceRosaceaBlood ClottingKeloid FormationImmune SuppressionIntraocular inflammation/Macular EdemaScleroderma or Connective Tissue DiseaseAny Active/Chronic InfectionsEye Pressure Problems (glaucoma)Swallowing ProblemsOngoing Steroid TreatmentNeuropathyNeuro-Muscular Disorder (ex. ALS, Myasthenia Gravis)Asthma or EmphysemaOngoing ChemotherapyAuto-immune DisordersMetal ImplantsFacial ImplantsAllergies (seasonal or to medication)None
Please list any other health problems or medical conditions (not listed above):
4) Does anyone in your family have a chronic skin condition?*

NoYes
If "yes", what?
5) Does anyone in your family have a chronic pigmentation disorder?*

NoYes
If "yes", what?
6) Any recent surgeries?*
7) Have you been diagnosed (past/present) with depression, anxiety, panic attacks, or other psychiatric issues?*

NoYes
Social History:
1) Do you drink alcohol?*

NoYes
If "yes", how much/often?
2) Do you smoke?*

NoYes
If "yes", how much/often?
3) Do you exercise?*

NoYes, occasionallyYes, regularly
4) Please describe your diet:*

A lot of room for improvementSome room for improvementVery Healthy
5) Are you pregnant?*

NoYes
6) Are you currently breastfeeding?*

NoYes
7) Are you planning to become pregnant?*

NoYes
Medication and Allergies:
1) Please list ALL medications (including OTC) you are currently taking:*

AntibioticsBlood ThinnersBirth ControlHormonesMuscle RelaxersCoumadinAsprinNSAIDS (Motrin, Advil, Aleve)IOP (Intraocular Pressure) MedicationLovenoxNoneOther
2) Have a pacemaker, internal defibrillator, or other implanted device?*

NoYes
3) Have you ever used Accutane?*

NoYes
If "yes", when did you last use it?
I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the health care providers at RENEW of my current medical or health conditions and to update this history with any changes. I understand that my current medical is essential to determine and carry out any appropriate treatments or procedures.
Patient Signature*

First NameLast Name
Date*

MonthDayYear
Date
Reviewed with Patient

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Client Medical History Assessment

Patient Medical History