PATIENT MEDICAL HISTORY

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1 PATIENT MEDICAL HISTORY Today s : Name: of Birth: Address: Social Security Number: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Preferred Contact Number: Emergency Contact Number: Emergency Contact: Address: May we you? How did you hear about us? Sex: Female Male Marital Status: Single Married Divorced Widowed Separated Work Status: Full-Time Part-Time Self-Employed Retired Unemployed What treatment areas would you like to discuss with our physician/staff? Face & Jowls Neck (under chin) Upper Arms Upper Back (bra line) Sacral Area Flanks (love handles) Upper Abdomen Umbilicus Lower Abdomen Hips Outer Thighs Inner Thighs Knees Calves Ankles Female Breasts Male Chest (breasts) Buttocks/Banana Folds Lipoma Other:

2 Page 2 of 5 Check all services you are interested in Laser Hair Reduction Pigmented Lesions or Brown Spot Removal Laser Vein Removal 3D Liposculpture Micro Tuck CHANGES Injectables Mesotherapy/LipoDissolve Facials MicroLaser Peels VelaSmooth Skin Tyte Vibraderm G-SHOT ProFractional Other: Do you have rosacea? Do you have wrinkle concerns? Do you have scarring concerns? Do you have sun damage concerns? Do you have pigmentation concerns? Do you have broken capillary concerns? Have you been on Accutane in the past 6 months? If yes, explain: Have you had any hernias, scars or prior surgery in the body area(s) you would like treated? If yes, explain providing date of surgery, surgery performed, etc.: Have you ever before had a Liposuction or LipoDissolve treatment or procedure? If yes, explain providing date of treatment, treatment description, area treated, etc.:

3 Page 3 of 5 Have you ever had a blood clot? If yes, explain providing date, description, etc.: Current Prescribed Medications: Current Over-the-Counter Medications: Current Herbal Remedies: Do you take Aspirin, Ibuprofen or NSAID s? If Yes, which one and how often? Do you smoke or chew tobacco? How much? How many years? Do you drink alcohol? If Yes, how much and how often? Do you exercise? If Yes, what type and how often?

4 Page 4 of 5 Do you have any allergies, including but not limited to medications, substances, dairy, peanuts, soy, latex? If yes, explain providing allergy, description, etc.: Have you had any of the following? (circle all that personally apply to you) Asthma Arthritis Anemia Autoimmune Disorder Anxiety Chronic Diarrhea Clotting Disorder Colon Problems Diabetes Suicide Attempt Heart Murmur Easy Bruising Excessive Scarring Excessive Bleeding Depression Heart Attack Heart Condition Heart Valve Replacement Heart Failure Bulimia High Blood Pressure Hepatitis HIV (AIDS) Irregular Heart Beat Anorexia Intestinal Problems Keloid Scars Kidney Disease Liver Disease Drug Abuse Lung Disease Multiple Sclerosis Muscular Dystrophy Mitral Valve Prolapse IV Drug Use Cold Sores/Herpes Permanent Make-Up Tattoo Pregnant Miscarriages Migraines Rheumatic Fever Shortness of Breath Seizures Stroke Stomach Problems Thyroid Disorder Cancer (what kind): Other: If yes, please explain:

5 Page 5 of 5 Acne Do you have a history of breakouts? If so, what is the frequency of your breakouts? Frequent Occasional Rarely Do you experience cystic breakouts? Do you have any scarring as a result of your acne? Skin Background Have you had prolonged sun exposure or tanning bed usage in the past three (3) days? If yes, are you currently sunburned? Do you use chemical tanning solutions? Do you use tanning beds? If yes, how often? Do you use sunscreen on a regular basis? Have you waxed, used depilatories, bleaches or other chemical processes? If yes, please explain providing the date last used, product, etc. Have you ever had microdermabrasion? Have you ever had a chemical peel? Have you ever had laser resurfacing? Have you had Botox or Collagen injections in the past six (6) months? If yes, please explain providing date of treatment, injectable used, area treated, etc. Do you use topical ointments? Retin-A Glycolic Lactic Acid Hydroquinone Other What type of skin care products are you currently using? Witness Signature

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