Consult Intake Form Page 2
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No
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Are you allergic to eggs, cow milk protein or human albumin? If yes, please list:
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Do you have any allergies to latex?
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Do you have any neuromuscular or autoimmune diseases? If so, please list:
Do you have any implantable devices ? If so, please list:
Please check any health problems, past or present:
⃝ Seizures
⃝ Diabetes
⃝ Diabetes
⃝ Heart Problems
⃝ High Blood Pressure
⃝ Thyroid
⃝ Skin Cancer ⃝ Asthma
⃝ Cystic Acne
⃝ Lupus/Scleroderma
⃝ Hepatitis
⃝ Cancer
⃝ Vasovagal Syncope/Fainting
⃝ Other:
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Personal/Social History
Yes
No
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Do you spend a lot of time outdoors? Hours per day?
or Per week?
Do you routinely use sunscreen? If so, SPF?
Have you ever used a tanning bed or self-tanners? Last time?
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Do you smoke? How much? ______ How Long? _____ When did you quit? _____
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Do you have any tattoos or permanent makeup? If so, where?
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Do you have body piercings? If so, where?
Skin Health History
Yes
No
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Are you using any topical creams, lotions or oral antibiotics prescribed for a skin
condition? If yes, please list:
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Have you ever had any of the following injectable or implants?: ⃝ Botox/Dysport
⃝ Juvederm ⃝ Radiesse ⃝ Restaylane ⃝ Perlane ⃝ Silicone ⃝ Hylaform ⃝ Collagen
⃝ Other: _________
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