BEAUTYNP

IV and AESTHETICS by MARINA

MEDICAL AESTHETIC CHART

Patient Information:

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Email

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

Answer

b. Do you have any chronic medical conditions? If yes, please specify:

YES

NO

Answer

c. Are you currently taking any medications? If yes, please list all medications, including over-the-counter drugs and supplements:

YES

NO

Answer

2. Allergies:

a. Are you allergic to any medications, substances, or materials? If yes, please specify:

YES

NO

Answer

b. Have you ever had an allergic reaction to any cosmetic or aesthetic treatments? If yes, please specify:

YES

NO

Answer

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

Answer

4. Skin Conditions:

a. Do you have any known skin conditions, such as eczema, psoriasis, or rosacea? If yes, please specify:

YES

NO

Answer

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

Answer

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

Answer

6. Smoking and Alcohol Consumption:

Do you smoke?

YES

NO

Do you consume alcohol regularly?

YES

NO

7. Expectations and Concerns:

Please describe your aesthetic concerns, desired outcomes, and any specific areas you would like to address:

I hereby certify that the information provided above is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the healthcare professional of any changes to my medical history or circumstances that may affect my eligibility for aesthetic treatments.

Date

Month

Day

Year

Signature

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