Oneuaesthetics.com

Physicians of Aesthetic Medicine
Last Name: __________________________________ First Name: ______________________________ Address: _____________________________________________________________________________ City: __________________________________ State: ____________ Zip Code: __________________ Date of Birth: _________________________________ Sex:  Female  Male Telephone: Home: _______________________________ Work: _____________________________ Cel : _________________________________ Family Doctor: _____________________________________ Phone: ____________________________ Pharmacy: ________________________________________ Phone: ____________________________ Emergency Contact: _________________________________ Phone: ____________________________ *Email: ________________________________________ Referral Source: _____________________ *May we contact you regarding promotions, specials, or events? ____ Yes ___ No
*PRIVACY: We will only use your email address for internal marketing purposes*

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS:
1. Do you have ANY current or chronic medical il nesses we should know  Yes  No
about? If yes, please check appropriate boxes:
 Other: _________________________________________________________________________
2. Do you take/use ANY medications, herbal or natural supplements, or topical on a regular or daily basis?
If yes, please check the appropriate boxes:
 Non-Steroidals (ex. Advil, Celebrex)  Steroids (Prednisone, Medrol Dose Pack) Physicians of Aesthetic Medicine

3. Have you taken ANY of the “as needed” medications listed below in the past 10 days? If yes, please
check the appropriate boxes:

 Aspirin
 Non-Steroidals (ex. Advil, Celebrex)  Steroids (Prednisone, Medrol Dose Pack)  Other: _____________________________________________________________________________ 4. Are you using any of the following topical products?

 Retin-A®
5. Do you have ANY al ergies? If yes, please check the appropriate boxes:
 Other: _____________________________________________________________________________
6. Medical History
(For women) Are you or could you be pregnant? (For women) Are your menstrual periods regular? Do you have a history of Herpes I or II in the area to be treated? Do you have a history of keloid scarring? Have you taken Accutane or anticoagulants in the last 6 months? Do you have any permanent make-up, implants or tat oos? _______________________________________________________________________________________ Have you had unprotected sun exposure, used tanning creams or tanning beds in the 7. Family Hx:
8. Social History:
If yes, how much? ______________________________ If yes, how much? _____________________________ _____________________________________________ Physicians of Aesthetic Medicine

9. Please indicate which of the following concerns you have about your skin:
10. Please indicate a service you are interested in or would like more information on:
looking skin through light therapy  Microdermabrasion to gently exfoliates and resurfaces the skin and help reverse the signs of 11. Have You Ever Had Any of the Following Treatments?
Date of last treatment? _____________________________ Type, area and date of last treatment? _________________ Date of last treatment? _____________________________ Date of last treatment? _____________________________ Date of last treatment? _____________________________ Area and date of last treatment? ______________________ Type of laser, treated area, and to improve what? _________ _________________________________________________ Date of last treatment? ______________________________ Type and date of surgery: ___________________________
12. Skin Care:
Do you have a regular skin care regimen? ___ Yes ___ No Products used: __________________________ Do you regularly wear sunscreen? ___ Yes___ No Do you feel that your products are successful y treating your skin conditions and concerns? ____ Yes ____ No ________________________________________________________________ ________________________________________________________________

Source: http://www.oneuaesthetics.com/documents/Patient-Forms/Patient-History-Form.pdf