2022 West Northwest Hwy
Suite 120, Grapevine, Tx 76051.

  Client Information and Health History  
Hormones: (for women only) yes No
Do you have regular periods? yes No
Are you going through menopause? yes No
Are you currently to become Pregnant? yes No
Are you currently Pregnant or nursing? yes No
Have you ever been treated by Endocrinlogist? yes No
  edical History: Please Check any that apply  
  ____Accutane   ____Fenital Herpes  
  ____Acne   ____Hirsutism  
  ____Auto Immune Disoreder (example: Lupus)   ____HIV, STD’s  
  ____Blood Disorders(Blood Thinners)   ____Hormonal Imbalance  
  ____Cancer   ____Metal Pins in Body  
  ____Cold Sores   ____Pacemaker  
  ____Dermatitis   ____PCDS (Polycystic Ovary)  
  ____Epiliepsy   ____Shingles  
  ____Folliculitis   ____Steroid or Hormonal Therapy  
  • Are you currently being treated for any Medical conditions not listed above?
  • yes No
  • Are you currently taking any medications? Example: antibiotics, birth control, over the counter
  • yes No
  • Have you ever used Accutane?                
  • yes No
  • Do you have any allergies?            
  • yes No

    I understand that withholding information about my health could affect the outcome of my treatments or procedures; all of my health information stated above is current, accurate and true.  I agree that the information listed above has been reviewed and presented with my clear and understanding of what this procedure involves.

    All of my questions have been addressed to my satisfaction.

      Client Signature Date:  
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