Initial Visit Questionnaire/History

Todays Date:__________________
Name___________________________________ DOB _____________________
Medical History:
Who is your family physician __________________________________________
Height __________ Weight _________
ALLERGIES:________________________________________________________
Preferred Pharmacy _________________________________________________
Do you have or have you had in the past any problems taking medications?
No
Yes which ones? Please explain_______________________________
_________________________________________________________________
Please list all prescribed/over the counter medications
1. ___________________ 4. ___________________
2. ___________________ 5. ___________________
3. ___________________ 6. ___________________

you are currently taking:

7. ___________________
8. ___________________
9. ___________________

Do you take Aspirin, Coumadin, Excedrin, Motrin, Vitamin E, Fish oil or any thing
which thins your blood?
No
Yes Which ones? ___________________________________________
Do you smoke? _________ If so, how much per day? _________
How many years have you smoked? ________
If you used to smoke, how long ago did you quit? _________
How many years did you smoke? ________
Female only: Are you currently pregnant, breastfeeding or planning on becoming
pregnant?
No
Yes
Current Medical Problems
1. ______________________________ 4. ______________________________
2. ______________________________ 5. ______________________________
3. ______________________________ 6. ______________________________
Past Surgeries: ____________________________________________________
_________________________________________________________________

Blood Transfusions:

No

Yes

Previous hospitalizations/operations:
_________________________________________________________________
_________________________________________________________________
Circle any of the following illnesses you have or have ever had in the past:
Eye Disease
Vision Problems
Cold Sores
Lupus
Hepatitis
Numbness

Shingles
Autoimmune Disease
Muscle Weakness
Myasthenia Gravis
Multiple Sclerosis
Neurological Disorders

Lambert-Eaton Syndrome
Severe Allergy/Hypersensitivity
Amyotrophic Lateral Sclerosis (ALS)
Lidocaine Hypersensitivity/Allergy
Parkinsons Disease
Herpes

Do you have current or a history of cancer, especially malignant melanoma or

recurrent non-melanoma skin cancer, or pre-cancerous lesions such as multiple
dysplastic nevi?
No
Yes
Do you have any implantable devices, pacemakers or metal implants such as
AICD, pacemaker, artificial joints, or rods?
No
Yes
Do you wear contact lenses?

No

Yes

Have you ever used Accutane before?

No
Yes If Yes, when
__________________________________________
Do you have a history of keloid scarring?

No

Do you have a history of Livido reticularis?

Yes

No

Do you have a history of Erythema ab igne?

No

Yes
Yes

When were you last exposed to the sun? ________________________________

Do you use tanning lotions?

No

Yes

Which of the following best describes your skin type? (Please circle one skin type
number)
1

Always burns, never tans

Always burns, sometime tans

Sometimes burns, always tans

Rarely burns, always tans

Brown, moderately pigmented skin

Black skin

Have you used any of the following hair removal methods in the past six weeks?
shaving
depilatories

waxing

electrolysis

tweezing

stringing

Cosmetic History:
Have you ever had a bad reaction with a skin product?
No
Yes which ones?
___________________________________________
Have you had plastic or reconstructive surgery before?
No
Yes which type of surgery? __________________________________
My current Cosmetic Doctor or Provider is _______________________________
Have you used Botox before?
No
Yes when was your last injection?
_____________________________
Did you experience any problems?
No
Yes _____________________________________________________
Have you ever had eyelid or eyebrow drooping after Botox?

No

Yes

Have you used dermal fillers before?

No
Yes which ones?
___________________________________________
What areas were filled? ______________________________________________
Did you experience any problems?
No
Yes _____________________________________________________
Have you had IPL/Laser Treatments before?
No
Yes which ones?
___________________________________________
Did you experience any problems?
No
Yes _____________________________________________________
Have you had any other cosmetic treatments?
No
Yes _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you had esthetic skin care treatments before (Facials, Microdermabrasion,
etc.)?
No
Yes which ones? ____________________________________
_________________________________________________________________
Do you have a skin care routine?
No
Yes products used _________________________________________
_________________________________________________________________
The reason(s) for my visit:
Wish list:
What 3 things would you most like to improve about your appearance?
1) ____________________________________________________________
2) __________________________________________________________________
3) __________________________________________________________________

How much improvement are you expecting?

100%
30%

80% - 90%

60% - 70%

40% - 50%

20% -

We require a 48 hour cancellation notice and if less than that a $50 cancellation
fee will be assessed on your next visit.
I acknowledge that all my answers on this form are accurate and truthful and I will not
hold any staff responsible for any errors that I may have made in completing this form.
I understand that the information on this form is essential in determining my medical
and cosmetic needs and the terms of my treatment. I have read and understand this
information on this form and if any changes to my medical history or health change, I
will inform the office personnel as soon as possible.

Signature ______________________________________ Date ______________