Client Medical Questionnaire Template

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CLIENT QUESTIONNAIRE
Name: __________________________________________ Date: _________________
Date of Birth: ____________________
MEDICAL INFORMATION:
NO
YES
____ ____ Allergies – history of severe allergy or anaphylaxis
____ ____ Aspirin, Ibuprofen: If yes, when? ________________________________
____ ____ Autoimmune disease, HIV, Lupus, Hepatitis
____ ____ Bruise easily, Cuts
____ ____ Currently Pregnant or Breast Feeding?
____ ____ History of Keloids scarring
____ ____ Currently on immunosuppressive therapy
____ ____ Currently tanning or tanning booth
____ ____ History of oral herpes (fever blisters)
____ ____ Any condition not listed: _______________________________________
____ ____ Currently under the care of a physician?
____ ____ Currently taking any medication (including OTC & Herbal supplements
taken regularly)? Please List: ____________________________________
__
____________________________________________
_________________________
I am interested in the following services:
Radiesse ______ Juvederm ______ Botox ______
Reviewed by: _________________________________ Date: _______________
Reviewed by: _________________________________ Date: _______________
Reviewed by: _________________________________ Date: _______________
Reviewed by: _________________________________ Date: _______________
Reviewed by: _________________________________ Date: _______________
Reviewed by: _________________________________ Date: _______________
PATIENT TO COMPLETE
Updated 9/6/11

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