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MEDICAL AESTHETIC CHART

BEAUTY MD

80-15 188th street

Queens, NY 11423

929-227-3304

Beautymdnyc@gmail.com

https://www.beautymd.fit

Patient Information:

Birthday
Month
Day
Year

Medical History:

Please provide accurate and complete information regarding your medical history. This information is crucial for ensuring your safety and determining the most appropriate treatment options.

1. General Health:

a. Are you currently under the care of a physician? If yes, please provide the name and contact information of your physician:
YES
NO
b. Do you have any chronic medical conditions? If yes, please specify:
YES
NO
c. Are you currently taking any medications? If yes, please list all medications, including over-the-counter drugs and supplements:
YES
NO

2. Allergies:

a. Are you allergic to any medications, substances, or materials? If yes, please specify:
YES
NO
b. Have you ever had an allergic reaction to any cosmetic or aesthetic treatments? If yes, please specify:
YES
NO

3. Previous Aesthetic Treatments:

a. Have you previously undergone any aesthetic treatments? If yes, please provide details, including the type of treatment, date, and outcomes:
YES
NO

4. Skin Conditions:

a. Do you have any known skin conditions, such as eczema, psoriasis, or rosacea? If yes, please specify:
YES
NO
b. Have you ever been diagnosed with skin cancer? If yes, please provide details, including the type of skin cancer and treatment received:
YES
NO

5. Pregnancy and Breastfeeding:

a. Are you currently pregnant or breastfeeding? If yes, please inform us, as certain treatments may not be suitable during this time.
YES
NO

6. Smoking and Alcohol Consumption:

Do you smoke?
YES
NO
Do you consume alcohol regularly?
YES
NO

7. Expectations and Concerns:

Date
Month
Day
Year
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