Medical History Form
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18119 Isabella Lane, Suite 100
Brentwood, TN 37027
Office: (615) 376-7700
Fax: (615) 376-7775
Web:
MEDICAL HISTORY FORM
Patient Name________________________________________________________
Date________________________
Date of Birth_____________
Sex ______M ______F
Age_______
Height________
Weight________
General Medical History:
Do you or have you ever had any of the following problems? Circle Y for Yes and N for No
Bronchitis
Y
N
Diabetes
Y
N
Emphysema
Y
N
Thyroid
Y
N
Asthma
Y
N
Herpes - Mouth
Y
N
Kidney or Bladder
Y
N
Herpes - Genital
Y
N
Chronic Cough
Y
N
Basal or Squamas Cell
Y
N
Morning Cough
Y
N
Cancer
Y
N
Shortness of Breath
Y
N
Melanoma
Y
N
Wheezing
Y
N
Arthritis / Joint Deformity
Y
N
High Blood Pressure
Y
N
Fainting
Y
N
Blood Clot
Y
N
Convulsions, Epilepsy, or Seizures
Y
N
Chest Pain
Y
N
Rosacea
or Acne
Y
N
Pacemaker / Defibrillator
Y
N
Thinning Lashes
Y
N
Heart Attack
Y
N
Onychomycosis / Toe Nail Fungus
Y
N
Heart Murmur
Y
N
Are you Pregnant or Breast Feeding
Y
N
Irregular Heartbeat
Y
N
Are you planning on being Pregnant
Y
N
Phlebitis
Y
N
Ingrown Hairs
Y
N
Inflammation of Veins
Y
N
Irritation from Shaving
Y
N
HIV or AIDS
Y
N
What is your current method of Hair Removal?
Current and/or Recent Medications:
Allergies to Medications:
Prior Cosmetic Procedures:
Circle Y for Yes and N for No
Botox
Y
N
Microdermabrasion
Y
N
Fillers (Juvederm, Collagen, Etc)
Y
N
Intense Pulse Light Rejuvenation
Y
N
Laser Resurfacing
Y
N
Laser Hair Removal
Y
N
Chemical Peels
Y
N
Laser Vein Treatment
Y
N
Please Circle the procedures that you would like more information on:
Laser Hair Removal
Botox
Dermal Fillers
Dermal Fillers
Botox
Laser Skin Resurfacing
Brown Spots / Sun Damage
Skincare Products
Chemical Peels
Microdermabrasion
Acne Treatments
Fat Reduction
Onychomycosis / Nail Fungus
Use of RetinA or topical Retinoids?
Y
N
Are you currently using Accutane?
Y
N
History of Use of Accutane?
Y
N
Do you routinely use Sunscreens? Which SPF? ____
Y
N
Social History:
Do you Smoke or use Tobacco?
Y
N
Do you drink Alcohol?
Y
N
# per Day_____, # per Week_____, or # per Year_____
Marital Status: ___________ Children: ____________
Hobbies: ______________________
Occupation: __________________
What type of Skincare products do you currently use for your face and body?
Are you currently under the care of a Dermatologist? Y or N
If Yes, why?
PATIENT SIGNATURE:
DATE:
REVIEWED BY:
DATE:
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