Patient Intake Form printable pdf download

Patient Intake Form

Name

Today’s Date

_________________________________________________________

_____/______/_______

Last

First

Address:________________________________________________ City:________________ State:_____ ZIP:_________

) ____________ Preferred?  Home  Cell  Work

Home:(

)___________ Cell :(

) ____________ Work: (

Primary Care Physician/Phone ______________________________ Preferred Pharmacy Phone # __________________

 Email me info about specials and events

Birth date

E-mail

___/___ /____

______________________________

 Email me appointment reminders

 Please do not email me

How did you hear about us?

__________________________________

Please tell us your main concerns that brought you to our office today:

__________________________________

____________________________________________________________________________________________________

MEDICAL HISTORY: This information is necessary for your procedure. Please answer the following questions:

Are you using any prescribed medications?

 No

 Yes, List: ___________________________________

Do you take oral anti-coagulant (blood thinning) meds?

 No

 Yes, List: ___________________________________

Are you using any Herbal medications?

 No

 Yes, List: ___________________________________

Do you have ALLERGIES to any cosmetic ingredients,

 No

 Yes, List: ___________________________________

medications or foods?

______________________________________

 No

 Yes

Are you pregnant or trying to become pregnant?

Are you breastfeeding currently?

 No

 Yes

Do you use oral contraceptives?

 No

 Yes

Do you use hormone replacement therapy?

 No

 Yes

Do you smoke?

 No

 Yes, How much? __________ How long?__________

Do you use tanning beds?

 No

 Yes, How Often?__________ Last tan? ___________

Do you have any tattoos or permanent makeup?

 No

 Yes, List: ____________________________________

Have you ever used Gold Therapy?

 No

 Yes

Notes:

_________________________________________________________________________________________________

_______________________________________________________________________________________________________

Please check any health problems, past or present:

 Seizures/Epilepsy

 Heart problems

 PCOS

 Thyroid

 Hepatitis

 High Blood Pressure

 Hormonal Problems

 Cancer

 Asthma

 Autoimmune: (lupus, scleroderma)

 Vasovagal Syncope

 Sarcoidosis

 Diabetes(HbA1C____)

 Skin cancer (Type: ___________________)

 Other:______________________________________________________________________________________________

Do you have any of the following chronic skin disorders (Check all that apply)?

 Psoriasis

 Dermatitis

 Eczema

 Vitiligo

Melasma

 Herpes Simplex/Blisters

 Keloid Scarring

 Fever Blisters

 Cystic Acne  Cold Sores

 Other: __________________________________

In addition to the above, please tell us which skin conditions concern you the most (Check all that apply):

 Acne

 Scarring

 Sun Damage

 Unwanted Hair

 Brown spots (Hyperpigmentation)

 Pimples

 Sun Spots

 Clogged pores

 Uneven skin tone

 Visible exposed blood vessels

 Wrinkles

 Dry patches

 Enlarged pores

 Excessive oiliness

 White spots (Hypopigmentation)

 Blackheads

 Whiteheads

 Upper lip lines

 Hard bumps under skin

 Other: ______________________________________________________________________________________________

Rev 9/2012

Patient Intake Form

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