Aesthetic Medical History Form

A detailed intake form clinics and aesthetic centers use to gather a patient's medical history, allergies, and lifestyle habits before a cosmetic treatment.

Use this template

Name

Nombre

Apellido

Phone Number

Cell Number

Ok to Text?

Date of Birth (MM/DD/YYYY)

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Sex

Family Doctor

Emergency Contact

Nombre

Apellido

Emergency Contact's Phone Number

How did you Hear About Us?

Which Body Area(s) or Conditions Would you Like Treated? Write N/A if Not Applicable

Do you Have any Allergies to Medications, Foods, Latex, or Other Substances? Please List:

Do you Smoke?

Average per Day. Write N/A if Not Applicable

Do you Drink Alcohol?

Average per Day. Write N/A if Not Applicable

Do you Have any Current or Chronic Medical Conditions? (heart conditions, diabetes, autoimmune disorders, immunosuppression, blood disorders, cancer, infections, or any condition affecting healing or skin sensitivity)

If Yes, Please List Them. Write N/A if Not Applicable

Do you Have any Current or Chronic Skin Conditions? (vitiligo, eczema, melasma, psoriasis, allergic dermatitis, collagen disorders, skin cancer, or any other skin condition)

If Yes, Please List Them. Write N/A if Not Applicable

Are you Under a Doctor's Care?

If So, for What? Write N/A if Not Applicable

Do you Take any Medications (Prescription or Over-the-Counter), Including Vitamins and Herbal Supplements, on a Regular Basis?

If So, for What? Write N/A if Not Applicable

Do you Use any Topical Products (Medical or Non-Medical) on your Skin Regularly or Daily?

If So, for What? Write N/A if Not Applicable

Are you Taking Oral Steroids (e.g., Prednisone, Dexamethasone)?

Do you Have a Pacemaker or External Defibrillator?

Do you Have any Metal Implants Under the Area Being Treated?

Do you Have a History of Light-Induced Seizures?

Do you Have a History of Herpes in the Area Being Treated?

Do you Have any Open Sores or Lesions?

Have you Had Radiation Therapy in the Area Being Treated?

Do you Have a History of Keloid Scarring or Hypertrophic Scar Formation?

In the Last 6 Months, Have you Used Anticoagulants, Photosensitizing Medications, or Anti-Inflammatories?

List Product and Date Used. Write N/A if Not Applicable

In the Last 3 Months, Have you Used Glycolic Acid or Other Alpha/Beta Hydroxy Acid Products, Exfoliating or Resurfacing Treatments?

If So, for What? Write N/A if Not Applicable

Have you Had any Cosmetic Procedures in the Past 6 Months?

If So, for What? Write N/A if Not Applicable

Have you Had any Permanent Makeup, Tattoos, Implants, or Fillers (Collagen, Autologous Fat, Restylane, etc.)?

If Yes, List Locations and Dates. Write N/A if Not Applicable

In the Last Month, Have you Been Treated with any Botulinum Toxin (e.g., Botox or Dysport)?

If Yes, List Locations and Dates. Write N/A if Not Applicable

Have you Taken Accutane (or Isotretinoin Products) or Tretinoin (e.g., Retin-A, Renova) in the Last 6 Months?

Have you Had any Unprotected Sun Exposure or Used Tanning Creams or Tanning Beds/Lamps in the Last Month?

Are you Pregnant or Breastfeeding?

Are your Menstrual Periods Regular?

Have you Been Diagnosed with Polycystic Ovarian Syndrome?

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Aesthetic Medical History Form

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