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Patient Medical History Form
Appointment Date:
Patient's Last Name:
First Name:
Email
Birth Date:
Age:
Gender:
Height:
Weight:
Physician Name:
Pharmacy Phone Number:
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
Have you had any complications form previous cosmetic surgeries or procedures?
Yes
No
If yes, please explain:
Medical History (Please check any medical conditions that may apply to you):
Diabetes
Stroke
Seizures
Hepatitis
Renal failure
Hernia repair
HIV infection
Heart disease
Blood disorders
Psychiatric disorders
High blood pressure
History of radiation
Lung disease or asthma
Pacemaker or defibrillator
Anemia or blood disorders
Abdominal or colon surgery
Cancer within the last 5 years
Metal plates, implants or devices
Autoimmune disorders (like Lupus)
Have you ever been diagnosed with any of the following skin conditions?
Heat urticaria or hives
Vitiligo
Eczema
Psoriasis
Melasma
Diseases of the collagen
Herpes/cold sores/fever blisters
Skin cancer
Sensitivity or allergy to the sun
Abnormal scarring
Current Medications (Prescription, Over the Counter, Vitamins & Supplements):
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Drug Allergies
Reactions
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Have you taken any of the following medications in the last 6 months?
Doxycycline, Minocycline, Tetracycline
Blood Thinners
Accutane® or similar pill
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
How often?
Daily
Weekly
Monthly
Weekends only
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 areas to be treated?
Yes
No
Are you pregnant or nursing?
Yes
No
Do you have a history or Polycystic Ovarian Syndrome?
Yes
No
If there is any other important information about your health we need to know, please use the space below:
Person(s) authorized to discuss my protected medical information and receive copies of my medical history and records are:
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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.
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