medispa intake forms

Aesthetic Patient Information Form Page1 of 8

Aesthetic Patient InformationPatient’s Name: __________________________________________ Date:______________________

Do you have or have you ever had any of the following?Heart Disease ____Yes ___NO Skin Disease ____Yes ___NOKidney Disease ____Yes ___NO Bleeding Disorder ____Yes ___NOLatex Allergy ____Yes ___NO Diabetes ____Yes ___NOHepatitis ____Yes ___NO Stroke ____Yes ___NORespiratory Disease ____Yes ___NO Respiratory Condition ____Yes ___NOSevere Depression ____Yes ___NO Trying to Become Pregnant ____Yes ___NONeedle Phobia ____Yes ___NO Nursing Baby / Child ____Yes ___NOIncreased Pain Before or During Menses ____Yes ___NO

Please explain any ‘Yes” responses above: _________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Please list any other Disease / Condition not listed above or that YOU consider important:

______________________________________________________________________________________________

______________________________________________________________________________________________

Please list ANY disease / condition YOU are currently or were RECENTLY treated for:

______________________________________________________________________________________________

______________________________________________________________________________________________

Please Note that patients attempting to become pregnant, are Pregnant, Breastfeeding, suffer from InsulinDependent Diabetes, Hepatic Cirrhosis, Kidney disease [Insufficiency / Failure], Stroke, Cancer, onChemotherapy or Anticoagulants {Plavix, Coumadin, Asparin, etc.} ARE NOT eligible to receiveMESOTHERAPY. Please discuss this matter with us, so that we can determine what other / alternativetreatments may be available for you.

List all medications , Herbs, Vitamins, and Supplements taken in the last two weeks:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Please List Any ALLERGIES:______ NONE

______________________________________________________________________________________________

______________________________________________________________________________________________

_____________________________________________________________________________________________List all cosmetic treatments you have had [surgical and non-surgical]: ____ NONE

_____________________________________________________________________________________________

_____________________________________________________________________________________________

The results were: _____Satisfactory; other: ____________________________________________________


_____________________________________________________________________________________________

_____________________________________________________________________________________________

What concerns bring you here today:?_____________________________________________________________

_____________________________________________________________________________________________

What are your expectations: _____________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I understand that the above information is completed correctly to the best of my knowledge. I understand that if I haveany changes in the above information or my medical status, that it is MY responsibility to notify Dr. Garcia or UtopiaWellness Staff as soon as possible before any further treatment.

I understand that aesthetic treatment for cosmetic reasons are not covered by insurance companies and that payment isdue at the time the servicez(s) is /are rendered.

Patient Signature: ____________________________________________________ Date: __________________

Witness: __________________________________________________________ Date: __________________:


Please highlight the area(s) you desire treated

PATIENT NAME : _________________________________________________ DATE: _______________

Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patient Initials: ________________




Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



ACNE MEDICATIONSisotretinoin (Accutane)tretinoin (Retin-A)

ANTI-ARTHRITICSGold salt thiomalate (Solganol)

ANTINEOPLASTIC MEDICATIONSANTICANCER MEDICATIONS

dacarbazine (DTIC-Dome)fluorouracil (Fluoroplex;others)methotrexate (Mexate;others)vinblastine (Velban)

ANTIDEPRESSANTSamitriptyline (Elavil;others)bupropionclonipraminedesipramine (Norpramin,Petrofrane)doxepin (Adapin,Sinequan)fluoxetine (Prozac)imipramine (Tofranil)maprotilinemirtazapine (Remuron)nortriptyline (Aventyl,Pamelor)paroxetine (Paxil)protriptyline (Vivactil)sertraline (Zoloft)tricyclicstrimiprimine (Surmontil)

ANTIHISTAMINESastimizolebrompheniraminecetirizinecyproheptadine (Periactin)diphenhydramine (Benadryl;others)loratadine (Claritin)terfenadine

ANTI-INFLAMMATORcelecoxib (Celebrex)ibuprofen (Motrin)naproxen (Naprosyn)

ANTIBIOTICSAzithromycin (Zithromax)demaclocycline (Declomycin;others)doxycycline (Vibramycin;others)griseofluvin (Fulvicin-U/F;others)hexaclorophenelomefloxacin (Maxaquin)methacycline (Rondomycin)nalidixic acid (NegGram;others)oxytetracycline (Terramycin;others)quinolonessulfonamidessulfacyntinesulfamethazineulfamethizolesulfamethoxazole-trimethoprim (Bacrtim,Septra)sulfasalazinesulfathiazolesulfisoxazole (Gantrisin)tetracyclines

ANTIPSYCHOTICSchlorpromazine (Thorazine;others)fluphenazine (Permitil;Prolixin)haldoperidol (Haldol)perphenazine (Trilafon)phenothiazinespiperacetazide (Quide)prochloperazine (Compazine;others)promethazine (Phenergan;others)resperidonethioridazine (Mellaril)thiothixene

PHOTOSENSITIVE MEDICATIONSPlease circle any medications that you are taking or recently have been taking

Comments / Any other Photosensitive Medication which you are currently taking:___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________


trifluperazine (Stelazine;others)triflupromazine (Vesprin)trimeprazine (Termaril)

CARDIAC MEDICATIONSACE inhibitors (Vasotec)amiodarone (Cordarone)diltiazem (Cardizem)disopyramide (Norpace)losartanlovastatin (Mevacor)pravastatin (Pravachol)quinidinesotalolsimvastatin (Zocor)

CHELATING AGENTSDIURETICS

acetazolamide (Diamox)amiloride (Midamor)bendroflumethiazide (Naturetin;others)benzthiazide (Exna;others)chlorothiazide (Diuril;others)chlorthaldonecyclothiazide (Anhydron)furosemide (Lasix)hydroflumethiazide (Diucardin;others)hydrochlorothiazid (eHydrodiuril;others)methyclothiazide (Aquatensen,Enduron)metolazone (Diulo,Zaroxolyn)polythiazide (Renese)quinethazone (Hydromox)trichlormethiazide (Metahydrin;others)thiazides

HERBAL MEDICINESAdditional plant familiesAgrimony (Agrimonia eupatoria)Angelica root and fruit (Angelica species)Bergamot peel (Citrus bergamia)

Bitter orange peel (Citrus aurantium)Buttercup plant (Rannunculus species)Carrot familyCelery (Apium graveolens)Cow Parsnip (Heracleum lanatum)Dill (Anthium graveolens)Fennel (Foeniculum vulgare)Fig (Ficus carica)Goosefoot (Chenopodium species)Kella fruit (Ammi visnaga)Lemon peel (Citrus limonia)Lomatium (Lomatium dissectum)Lovage root (Levisticum officinale)Parsley (Petroselinum sativum)Psoralea seeds (Cullen corylifolia,Psoralea corylifolia) Queen Anne’s lace (Daucus carota)Rue leaves (Ruta graveolens)St John’s wort (Hypericum perforatum)Yarrow plant (Achillea millefolium)

HORMONALestrogen replacementoralcontraceptivesother hormones

HYPOGYCEMICSacetohexamide (Dymelor)chloropropamide (Diabinase;Insulase)glimipirideglipizideglybuidetolazimide (Tolinase)tolbutamide (Orinase;others)

SUNSCREENS - ContainingBenzophenonesPABA (p-aminobenzoic acid)

I agree that the information listed above has been reviewed and presented with my clear understanding of what thisprocedure involves.

Signed: ______________________________________________________ Date: _____________(Patient or person legally authorized to consent for patient)

Witness: ________________________________________________________________(To patient’s signature)

PHOTOSENSITIVE MEDICATIONSPlease circle any medications that you are taking or recently have been taking

medispa intake forms

Documents