Nouveau Medispa Medical History Form
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2Nouveau Medispa Medical History Form
Name: _____________________________________________ Date: ___________________
Address:______________________________________City/State/Zip:____________________
Home phone:___________________________ Cell phone:_____________________________
Email address:__________________________ DOB: ______________ Age:_____________
Referred by:
Doctor_______ Friend: _______Other (list):______________________
Employer:______________________________ Profession:_____________________________
Daily Medications including herbs:________________________________________________
Current skin care products:_______________________________________________________
General (please circle any that apply)
Allergies_______________
Asthma/Difficulty breathing
Skin or Nail Infections
Cold Sores/Shingles/Herpes
HIV/AIDS
Smoker
Pacemaker/Metal Implant
Depression
Anxiety/Panic
Diabetes
Thyroid disorder
Kidney Disease
Heart Disease
Seizures
Fibromyalgia
High/Low Blood Pressure
Neck/Back Pain
Neuro-muscular disease
Allergy Lidocaine
Allergy Epinephrine
Other (list):____________________
Other (please circle any that apply)
Excess pigment/freckles
Lack of pigment
Eczema, psoriasis or rashes
Thick or keloid scars
Skin reaction to treatments
Melasma/Mask of pregnancy
Acne/cystic acne
Skin cancer
Accutane when:______________
Rosecea
Broken capillaries
Previous Treatments (please circle any that you have had)
Botox/Dysport
Restylane/Perlane
Juvederm
Radiesse
Other fillers
Chemical Peel
Intense Pulsed Light
Laser/light treatment
Microdermabrasion
Permanent make-up
Retin-A/Renova Use
Thermage
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Parent category: Medical