Patient Medical History Form

Appointment Date*

Patient's First & Last Name*

First Last

Birth Date*

Age*

Gender*

Height*

Weight*

Physician name*

Pharmacy phone #

Reason(s) for Consultation*

Cosmetic History (Please check any procedures that may apply to you)

Face lift
Eyelid lift
Rhinoplasty
Lips
Fillers
Neuromodulators (Botox, Dysport, Xeomin)
Breast surgery

If "Fillers" was selected above, please input the name of the filler(s) below

Have you had any complications from previous cosmetic surgeries or procedures?*

Medical History (Please check any medical conditions that may apply to you)

Have you ever been diagnosed with any of the following skin conditions?

Current Medications (Prescription, Over the Counter, Vitamins & Supplements):

Drug Allergies

Reactions

Have you taken any of the following medications in last 6 months?

Doxycycline, Minocycline, Tetracycline*

Yes
No

Blood thinners*

Yes
No

Accutane® or similar pill*

Yes
No

Have you smoked in the past year?*

Yes
No

Do you use any other tobacco products?*

Yes
No

Do you drink alcoholic beverages?*

Yes
No

If Yes, how often?*

Have you used any tanning beds, lamps or products in the last 6 weeks?*

Yes
No

Do you have any permanent make-up or tattoos in area to be treated?*

Yes
No

Are you pregnant or nursing?

(women only)

Yes
No

Do you have a history or Polycystic Ovarian Syndrome?

(women only)

Yes
No

If there is any other important information about your health we need to know, please use space below:

Person(s) authorized to discuss my protected medical information and receive copies of my medical history and records are:

Authorized Name

Relationship

Date

I certify that the information provided on this medical history is correct and complete. Further, I understand that providing incomplete and incorrect information may not only jeopardize my health, but also render ineffective or harmful, any treatment I receive from Dr. Suneel Chilukuri.

Signature*

Date*

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