Patient Biographical Information
*First Name:   Middle Initial: *Last Name:	*Birthdate:     *Gender: Male Female
*Address:   *City:   *State/Province:   *Zip/Postal Code:   Email: Home Phone: Work Phone: 2nd/Cell Phone: How did you hear about our clinic? Doctor's Referral: Friend/Current Patient: Attended seminar/ Trade show (date/location): Newspaper    Website/Internet    Coupon    Yellow Pages    Magazine    Walk by I am interested in: (Please check all that apply) Botox Cosmetic    Hair Removal    Skin Rejuvenation/Wrinkle Reduction    Treatment of Age Spots/Sun Damage    Cosmetic Fillers (for lips or deep lines)    Cosmetic Smile Makeover    Medical History      Please select YES for the appropriate condition for which you have ever been treated.   NoYes  Acne   NoYes  Arthritis   NoYes  Autoimmune Disorder   NoYes  Blood Disorder   NoYes  Cancer (or Radiation Therapy)   NoYes  Diabetes/Diabetic Neuropathy   NoYes  Epilepsy   NoYes  Herpes (or Cold Sores):   NoYes  Hirsutism   NoYes  Hormonal Imbalance   NoYes  Keloid Scars/Other Scars   NoYes  Kidney Disease   NoYes  Local Anesthetic Sensitivity   NoYes  Melanoma   NoYes  Polycystic Ovarian Syndrome   NoYes  Port Wine Stain   NoYes  Psoriasis Steroid or Hormonal Therapy   NoYes  Shingles   NoYes  Skin Pigmentation   NoYes  Vitiligo   NoYes Do you use sunscreen? If "Yes" SPF: When you sunbathe, how does your skin respond?     Always burn, never tan    Usually burn, tan with difficulty    Almost never burn, tan very easily     Sometimes burn, tan about average    Rarely burn, tan easily    Never burn, always tan

Family Physician:

Drug Allergies:

Please list any past illnesses or surgeries:

Please list current medications (including aspirin, birth control, herbal medication, etc.):   NoYes Do you smoke? How many per day? Weight: Height:   NoYes Are you currently being treated for any conditions not listed? If yes, please specify:   NoYes Have you ever used (or are currently using) Vitamin A or Glycolic acid? If yes, please specify:   NoYes Have you ever used (or are currently using) Accutane? If yes, please specify:   NoYes Have you ever had a chemical peel? If yes, please specify:   NoYes Have you had laser treatments in the past? If yes, please specify:   NoYes Have you had "Botox" treatments in the past? If yes, please specify: When was the last time you: Waxed:     Used a depilatory: Area(s) treated? What products are you currently using on your skin? Do you have any particular skin sensitivities?   NoYes Have you ever been treated by an endocrinologist? If yes, please specify:   NoYes Do you sunbathe or use self-tanning lotions or use tanning beds? If yes, please specify how often?   NoYes Are you currently pregnant, breast feeding or do you plan to become pregnant in the next year? If yes, please specify: