New Patient Questionnaire

If you would rather fill in the form manually please download and print the following pdf document:
[HTR-New-Patient-Questionnaire]

If you wish to complete the form electronically please complete the requested information below and press the submit button at the end of the form.

First Name:
Last Name:
Date of Birth:
Address:
 
City:
State:
Zip:
Occupation:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
How did you hear about us?
 
Health History
Have you ever had any of the following (Mark all that apply)
Heart Disease Auto-immune Disease
Excessive bleeding or on blood thinners Myasthenia Gravis
High Blood Pressure Depression Anxiety
Diabetes Kelovalues or unusually large scars
Cold Sores or Fever Blisters Skin Cancer or unusual moles
Other:
Are you pregnant or nursing? Yes No
   
Do you smoke? Yes No
- Packs per day
- Number of years
   
Do you drink Alcohol? Yes No
- Amount per day
 
 

Are you taking any asprin-type medication?
i.e. Motrin, Aleve, ibuprofen, aspirin

 Yes No
   
Are you using Retin A? Yes No
   
Have you used Accutane in the past 2 years? Yes No
   
Last exposure to sun or tanning beds?
 
List All Medications you are currently taking (including over the counter, natural medicines and vitamins):
Please list all allergies
 
Which of the following have you had done before?
Botox: When ?
Injectable Fibers (such as Restylan): When ?
Laser Hair Removal:
IPL "Photofacial":
Chemical Peel or Laser Resurface:
Microdermabrasion:
 
Current Skin Care Brands:
 
Areas of Concern:
Anti-aging
Rosacea/Acne     
Oily Skin     
Fine Lines     		 Unsightly Vessels     
Deeper Wrinkles     
Poor Skin Texture     
Discoloration
Other, please state...
 
Which best describes your reaction to strong sunlight without sunblock?
Type I: Very fair skin that always burns and never tans
Type II: Fair skin that always burns and sometimes tans
Type III: Medium skin that sometimes burns and always tans
Type IV: Olive/light brown skin tha rarely burns and always tans.
Type V: Brown skin that never burns and always tans.
Type VI: Dark brown or black skin that never burns and always tans.
 
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