Home › Facial Patient History and PhysicalFacial Patient History and Physical Date: * Patient Name: * Email * Date of Birth: * Occupation: * Address: * Cell Phone: Home Phone: Emergency Contact Name and Phone: Medical History Do you have any of the following medical conditions (please check those that apply): * Cardiac Problems (e.g. pacemaker or defibrillator)High Blood PressureBleeding Disorders (bruise easily)Keloids/ScarringDaily use of anticoagulants or aspirinImpaired HealingDiseases stimulated by light (e.g. Epilepsy)CancerDiseases stimulated by heat (Herpes Simplex)Frequent cold soresSkin disorders or skin lesionsDiabetesHormone Imbalance (e.g. PCO)HepatitisMelasma/PIHThyroid DisorderAutoimmune disorder (e.g. Lupus, HIV/AIDS)None of the above Please explain if you checked any of the above: Medications Have you ever used Accutane for acne treatments? * YesNo Dates Used: Please list all prescription medications you are currently taking: * Please list all OTC medications and supplements you are currently taking: * Have you ever had an allergic reaction to the following (please check those that apply): * LatexLidocaineAnesthesiaTopical AnestheticOtherNone of the above Please explain: Female Patients: Are you pregnant?Are you breastfeeding? Surgical History (including cosmetic) – Please list all surgeries and the year they were performed: * Cosmetic Treatment History – Please list all treatments and the year that they were performed: * Are you under the care of a physician or dermatologist at this time? * YesNo Do you smoke? * YesNo Do you drink alcohol? * YesNoSkin Type Ethnicity: Please check all that apply (even if you are a combination of the below) * WhiteAsianMediterraneanBlackHispanicMiddle Eastern Which of the following describes best your skin reaction when you are in the sun? * Always burn, never tan (Type I)Burn easily, tan minimally (Type II)Burn and tan moderately (Type III)Rarely burn, tan easily (Type IV)Rarely burn, tan profusely (Type V)Never burn, tan profusely (Type VI) Are you tan now? * YesNo From sunFrom tanning bedFrom tanning lotion Will you be exposed to the sun in the near future? * YesNo Do you use sunscreen? * NeverSometimesAlways What SPF do you use? * How often do you apply your sunscreen during the day? * Do you have any problems with hyperpigmentation (dark skin coloration) or hypopigmentation (light skin discoloration)? * YesNo Location: What skin care products do you use? * Have you had any injections or fillers in the area to be treated? If so, please specify: * Do you have any tattoos (including permanent makeup)? * YesNo If yes, please specify the location: Do you have any moles, birthmarks, or any other dark lesions? * YesNo If yes, please specify the location: When were these lesions last checked by a physician? Patient Signature * Date * Disclaimer: This clinical form is presented for information purposes only. This document cannot and should not be used as a basis of diagnosis or choice of treatment, and is not intended to replace professional medical care or attention by a qualified practitioner. By completing this form, you're consenting to email and SMS marketing and can unsubscribe at any timeI agree to receive text messages from New Image Plastic Surgery, including appointment reminders, scheduling confirmations, post-procedure follow-ups, and occasional promotional offers. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. See our Privacy Policy for details on our SMS messaging program. We do not share or sell your mobile information to third parties. Protected by Recaptcha. Privacy & Terms
