Medical History Form

Today’s Date:

*** Please complete ALL the information; if Not Applicable, please write “N/A” ***

Patient’s Name:

Date of Birth:

Person Completing Form and how you are related to the patient:

(if you are the patient, write “self”)

When was your first visit with ENTOffice.org?

Regular (primary) Doctor:

How did you hear about ENTOffice.org?

If another person referred you, what is his or her name?

What areas of your face are you interested in enhancing today?

Medicines:

Does the patient take any medicines?

Yes No

If “Yes”, what do they take and when do they take them?

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Does the patient have allergies to any medicines?

Yes No

If “Yes”, what are they?

Explain what happens when the patient has a bad reaction to medicine:

Tobacco

Does the patient use tobacco?

Yes No

What type?

How much?

When did you start?

If the patient quit, how long ago?

Alcohol

Does the patient drink alcohol?

Yes No

If yes, how much?

Reproductive

Are you pregnant?

Yes No Not Sure

Are you nursing?

Yes No

Method of Birth Control:

Personal Medical History:

1. Do you have an active inflammatory process (skin eruptions such as cysts, pimples, rashes or hives)?

Yes No

2. Have you recently had an infection of any kind (sinus infection, UTI)?

Yes No

3. Have you recently had the flu or other viral illness?

Yes No

4. Do you have a history of oral herpes and if so when was your last breakout?

Yes No

5. Do you have an autoimmune disease (lupus, rheumatoid arthritis, MS)?

Yes No

6. Do you have a history of allergies, and have you ever had an anaphylactic reaction?

Yes No

7. Have you had surgical or nonsurgical cosmetic procedures before?

Yes No

8. Have you had any dental procedures or visits to the oral hygienist in the last month?

Yes No

Do you have any planned in the next month?

Yes No

9. Have you had any medical procedures or immunizations in the past month?

Yes No

10. Are you taking any blood thinners (aspirin, nonsteroidal anti-inflammatory drugs, and warfarin) or do you consume blood-thinning products (eg, salmon oil, vitamin E, ginkgo biloba, red wine, dark chocolate, grapefruit)?

Yes No

11. Have you ever seen a medical provider for your skin?

Yes No

If yes, explain:

12. Have you ever had Botox injected before?

Yes No

If yes, last injection date:

13. Have you ever had filler injected before?

Yes No

If yes, last injection date:

Medical History— Please check “Yes” if the patient has EVER had any of these problems

Autoimmune Disease

Yes No

Kidney Disease

Yes No

Bleeding Disorders

Yes No

Thyroid disorders

Yes No

High cholesterol

Yes No

Pneumonia

Yes No

Tuberculosis

Yes No

Cancers

Yes No

COPD (lung disease)

Yes No

Diabetes

Yes No

Heart disease

Yes No

High blood pressure

Yes No

Asthma

Yes No

Other past medical history:

Are you (the patient) having any of these problems RIGHT NOW? If yes, what?

Please tell us all the operations the patient has had (and when):

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Is there anything else we should know?

ENTOffice.org, PLLC Patient Registration Form

Today’s Date:

Patient’s Name:

Date of Birth:

Parent/Guardian (if minor):

Relationship:

Address:

City:

State:

Zip Code:

Phone:

Ok to leave a message?

Mobile:

OK to text appointment reminders?

Email:

OK to contact via email?

Sex:

Male Female Other

Pronoun (optional):

Social Security Number:

Are you Hispanic or Latino?

Yes No

Education/Employment:

If you (the patient) are a student: School Name:

Grade:

Patient or Parent/ Guardian: Employer:

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