Texasbizsolutions.biz

HEALTH INFORMATION FORM
Patient Name:____________________________ Date of Birth:__________________ Today’s Date:_______________ Address:________________________________________ City, State, Zip:___________________________________ Home Phone: ( )__________________ □ Work: ( )____________________ □ Cell: ( )_________________ □ (Place an X In the Appropriate Box Above To Indicate Your Preferred Contact Method) E-mail:_____________________________Occupation:_____________________Employer:_______________________ (Used for Office Correspondence Only) Primary Care Physician:___________________ Phone: ( )______________ Are You Currently Under a Physicians Care? Y / N Please Specify:_____________________________________ How did you hear about us?____________________________Referrer’s Name (if applicable)______________________ Emergency Contact:_____________________________ Relationship To Patient: _______________________________ Contact’s Phone: ( ) ________________________ Reason for Consultation?_________________________________ Have you ever had any of the following conditions?
(check all that apply)
ALLERGIES – Please List | Have you ever had: (Circle)

Medication Allergies:___________________________
Cosmetic Allergies:____________________________
Latex/Other Allergies:__________________________
Have you ever/are you currently using: (Circle)
Retin-A, Renova or any retinoic product:
WOMEN: Are you pregnant?__________ If yes – Due Date?________________ Are you lactating?___________
Please list all current medications/supplements that you take (including topical medications):______________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
HEALTH INFORMATION FORM – cont.
Previous Cosmetic Treatments (Circle) | What are your concerns about your skin?
What is your natural hair color?__________________________ Eye Color?_______________________________ Is your skin condition normal or abnormal?_____________________________________________________________ When did you last tan your skin?_____________________ Sun, tanning beds, creams?______________________ When a scar appears on your skin, is it significantly dark in color?___________________________________________ In your own words, describe your skin.________________________________________________________________ What are you hoping to improve with your skin?_________________________________________________________ Going back three generations, what is your family ancestry?_______________________________________________ Please list your skin care regimen:

AM Cleanser:____________________________________________________________________________________
Treatment:___________________________________________________________________________________
Moisturizer:__________________________________________________________________________________
SPF:________________________________________________________________________________________
Make-up:____________________________________________________________________________________
Other:_______________________________________________________________________________________
PM Cleanser:_____________________________________________________________________________________
Treatment:____________________________________________________________________________________
Moisturizer:___________________________________________________________________________________
Other:_______________________________________________________________________________________
*In an effort to keep our patients informed, we periodically send monthly email correspondence. By signing
below, I acknowledge and consent to receiving these emails. I may, however, opt-out at any time provided written
notice is given.
*In order to control our costs of billing, we request that office visits be paid at the time service is rendered.
Acceptable forms of payment are Cash, Visa, American Express and MasterCard. We apologize, but we do not
accept Checks or Discover.
Patient Signature:_________________________________________________ Date:____________

Source: http://texasbizsolutions.biz/lebeau/wp-content/uploads/2013/08/Health-Information-Form.pdf