Patient Form - LA Aesthetics Center

Patient Medical Data

Date Today *

First Name *

Last Name *

Date of Birth *

Pronouns

Birth Sex *MF

Gender Identity *Identifies as MaleIdentifies as FemaleFemale-to-Male (FTM)/Transgender MaleMale-to-Female (MTF)/Transgender FemaleGenderqueer, neither exclusively male nor femaleAdditional gender category or otherChoose not to disclose

Medical History

Check any conditions you are currently being treated for or have had in the pastHead/brain injuries or illnesses (e.g., concussion)Seizures, epilepsyEye problems (except glasses or contacts)Ear and or hearing problemsHeart disease, heart attack, bypass, or other heart problemsPacemaker, stents, implantable devices, or other heart proceduresHigh blood pressureHigh cholesterolChronic (long-term) cough, shortness of breath or other breathing problemsLung disease (e.g., asthma)Kidney problems, kidney stones, or pain/problems with urinationStomach, liver or digestive problemsDiabetes or blood sugar problemsAnxiety, depression, nervousness, or other mental health problemsFainting or passing outDizziness, headaches, numbness, tingling, or memory lossUnexplained weight lossStroke, mini-stroke (TIA), paralysis, or weaknessNeck or back problemsBone, muscle, joint or nerve problemsBlood clots or bleeding problemsCancerChronic (long term) infection or other chronic diseasesSleep disorders, pauses in breathing while asleep, daytime sleepiness or loud snoring

Medical History

Do you have any allergies? *YesNo(include medication, food, latex and environmental allergies)

Allergy to: *

Reaction *

Severity *MildModerateSevere

Do you take any medications? *YesNo(include non-prescription products)

Current Medication *(include non-prescription products)

Have you had any procedures or surgeries? *YesNo

Surgery / Procedure *

Approximate Date *

Are you interested in using the Doctors Care in-center pharmacy? *YesNo

Preferred Pharmacy

Pharmacy Name *

Pharmacy Location *

Preventative Screening

Have you had a colonoscopy? *YesNo

Approximate Date of Colonoscopy *

Have you had a mammogram? *YesNo

Approximate Date of Mammogram *

When was your most recent menstrual cycle? *

Family History

MotherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

FatherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

SisterHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

BrotherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

Maternal GrandfatherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

Maternal GrandmotherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

Paternal GrandfatherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

Paternal GrandmotherHigh Blood PressureDiabetesCancerOther (specify)

Other, specify: *

Social History

Do you smoke cigarettes? *YesNo

How many sticks per day? *

For how many years *

Do you vape or use an e-cigarette? *YesNo

How many times a day? *

For how many years *

Do you marijuana / recreational drugs? *YesNo

How many times a day? *

For how many years *

Immunizations

Did you get an influenza shot? *YesNo

When? *

Did you get a pneumococcal shot? *YesNo

When? *

Did you get a tetanus shot? *YesNo

When? *

Did you get COVID-19 shots? *YesNo

How many shots? *

When is the most recent shot? *

Patient Information and Consent

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Email Address *

Phone *

Ethnicity *Hispanic or LatinoNot Hispanic or Latino

Preferred Language *

Emergency Contact Name *

Relationship to Patient *

Emergency Contact Phone *

Legal Name of Guarantor/Responsible Party (First, Middle, Last) *Person responsible for payment

Date of Birth *

Email Address *

Patient Consent

Authorization for Release of Information

May we leave testing results or referral information in email? *YesNo

May we leave testing results or referral information in voicemail? *YesNo

Name of person who may receive information on your behalf regarding testing or referrals *

Patient or authorized person’s signature *

Date Signed *

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