Bair Medical Spa

Health History

Patient
Name:

General Medical Information
Are you taking any medication or vitamins? Yes No
If yes, please list the name of medication(s) or vitamin(s):
Are you currently under the care of a physician? Yes No
If yes, for which condition(s):
What treatment did you receive?
Please provide the name of the physician:
Have you ever been treated for, diagnosed as having, or are you currently suffering from and of the following?

Skin
Skin tumors, skin cancer or melanoma? YesNo Explanation:
Do you have sensitive skin or bruise easily? YesNo Explanation:
Scars from surgery or skin graft? YesNo Explanation:
Keloids? YesNo Explanation:
New stretch marks (less than 2 months)? YesNo Explanation:
Abnormal skin sensitivity? YesNo Explanation:
Skin disorder, open sores, inflammation, eruption or infection? YesNo Explanation:
History of Eczema, Psoriasis, or Rosacea? YesNo Explanation:
Any generalized skin disorder, inflammation, eruption or infection? YesNo Explanation:
When did you start noticing the appearance of cellulite? YesNo Explanation:
Where do you have cellulite? YesNo Explanation:

Infectious Disease
Any infectious progressive illness, such as Hepatitis YesNo Explanation:
Acquired Immune Deficiency Syndrome or other conditions YesNo Explanation:

Cardiovascular/Neurological
Any circulatory disorders? YesNo Explanation:
High blood pressure? YesNo Explanation:
History of heart disease? YesNo Explanation:
Deep vein thrombosis and/or unexplained pain? YesNo Explanation:
Phlebitis within the last two years? YesNo Explanation:
Varicose veins, capillary/vascular problems? YesNo Explanation:
Neuromuscular/neurological disorder such as seizures, etc.? YesNo Explanation:
Suffered from fainting, convulsions, recurrent headaches, dizziness, paralysis, stroke, nervous disorder or mental disorder? YesNo Explanation:

Musculoskeletal
Active rheumatoid arthritis? YesNo Explanation:
Osteoporosis? YesNo Explanation:
Muscle, nerve or joint disorder? YesNo Explanation:

Metabolic
Diabetes? YesNo Explanation:
Are you sensitive to cold temperature? YesNo Explanation:
Have you been on a diet/ weight loss program in the last year? YesNo Explanation:

Cosmetic
Liposuction or cosmetic surgery? YesNo Explanation:
Have you received any injections (collagen, cortisone, etc)? YesNo Explanation:
Other cosmetic procedures? YesNo Explanation:

OB/GYN
Are you pregnant? YesNo Explanation:
Have you recently started using contraceptive pills? YesNo Explanation:
Do you have a regular menstrual cycle? YesNo Explanation:
Are you under hormonal treatment? YesNo Explanation:
Do you suffer from PMS (Pre-Menstrual Syndrome)? YesNo Explanation:
Cesarean sections? YesNo Explanation:
Anti-coagulant medication? YesNo Explanation:

Past History & Medications
Allergies? YesNo Explanation:
Recent major surgery (less than 2 months)? YesNo Explanation:
Cancer? YesNo Explanation:
Are you taking anti-depressant medication? YesNo Explanation:
Are you taking medication for venous problems? YesNo Explanation:
Do you suffer from constipation? YesNo Explanation:
Are you taking diuretics? YesNo Explanation:
Are you taking laxatives? YesNo Explanation:
Have you taken Accutane in the past 3 months? YesNo Explanation:
Are you Retin A? YesNo Explanation:
Are you taking diet pills? YesNo Explanation:
Are you taking antibiotics? YesNo Explanation:
Do you drink Alcohol? YesNo Number Daily:
Do you smoke? YesNo Number Daily:
101 Hospital Loop NE, 111, Albuquerque, NM 87109. 505-881-1532. Info@BairMedicalSpa.com