Consultation Date of Birth: MM-DD-YYYY Age: Height: Weight: First Name: Last Name: Address: City: State: Zip Code: Best phone # to reach you: Alternative # : Emergency Contact # : Email: Form of Contact(Preferred Contact): Phone Call Email Text Message Reason for your visit: Are you currently under another physician care? Yes No If Yes, for what condition and Doctor’s name? Doctor’s contact number: Do you have or had? Please CHECK any that may apply of the following: Anemia Anesthesia Reaction Arthritis Asthma Back Pain Bleeding Tendency Blood Clots / DTV Shortness of Breath Wheezing Breast Cancer Chest Pain Diabetes Dry Eyes Epilepsy Fibromyalgia Stroke Fainting or Blackouts Glaucoma Heart Disease Heart Murmur Hepatitis Herpes Simplex / Fever blisters High Blood Pressure Thyroid Disease HIV / Aids Kidney Disease Liver Disease Lung Disease Migraine Headaches Peptic Ulcer Pneumonia Vision Deficits Other: Have you ever had previous surgeries? Yes No If Yes, what type of surgery? Date of Sugery: MM-DD-YYYY Name of Surgeon: Please list all known allergies (1 per line): Do you take: (Please CHECK any that may apply to the following) Aspirin, Ibuprofen or NSAIDS Coumadin (Warfarin) Arthritis Medicine Retin A Accutane Steroids in the past year Birth Control Pills Vitamins & Herbal Supplements List any other medications you are currently taking (1 per line): Family History: PERSONAL HISTORY Do you smoke? Yes No Packs per day: Do you usually drink 2 or more alcoholic beverages daily? Yes No Do you drink more then 6 cups of coffee/caffeinated drinks daily? Yes No Have you ever received treatment for alcohol or drug abuse? Yes No Do you often get depressed or feel unhappy? Yes No Did you ever have a nervous breakdown? Yes No Are you easily able to get upset or irritated? Yes No Do you tend to hold a “Grudge” when someone angers you? Yes No Have you ever considered consulting a psychiatrist or psychologist? Yes No If you answered Yes to any of the questions or have any medical problems not addressed please explain in detail (when, how long, complication)? FOR WOMEN ONLY Have you ever been pregnant? Yes No I’m not a woman! If Yes # of pregnancies # of children Did you breast feed? Yes No I’m not a woman! Last mammogram: Results of Mammogram? Normal Abnormal I’m not a woman! How did you hear about us? Google Yahoo Bing Newspaper / Magazine Website Friend / Family Locate a Doc Facebook Twitter Comment: Verification code: MUZGB I am aware I filled out all the information contained in this form and I am responsible for them. I also understand that this information does not serve as a consultation for any type of procedure that will be done by the doctor. All information in this questionnaire is confidential and kept in absolute privacy. After sending this information any complaint claiming ignorance cannot be made.*** I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update my history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. ***
