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DermaHealth Med Spa, Laser & Skin Care Clinic

Call Us! 417-447-7777

Proudly Serving Springfield, MO

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Client History

Download Fillable Client History Form (PDF)

Step 1 of 5

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Date
Name
First Last
Date of Birth
Age
Home Phone
Work Phone
Cell Phone
Email Address
Sex
Emergency Contact
Phone Number
How did you hear about us?
Occupation
Marital Status
Height
Weight

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Surgical History
List surgical procedures including plastic surgery.
Other serious Illness/operations
Date of last chest x-ray
Date of last EKG

Medications

Name	Dosage	Frequency

Allergies and type of reaction

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Nutritional Supplements
Androstenedione
Arimedex
DHEA
Estrace
Estradiol
Estriol
Estrone
Growth Hormone
Human Growth Hormone
Melatonin
Pregnenolone
Premarin
Progesterone
Provera
Tamoxifen
Testosterone
Thyroid
Vitamin A
Vitamin B3
Vitamin B6
Vitamin B12
Vitamin C
Vitamin D
Vitamin E
Beta Carotene
Calcium
Co Q10
Chromium
Digestive Enzyme
Folic Acid
Iron
Magnesium
Selenium
Zinc
Probiotic
Social
Alcohol use
- Yes
- No
Amount
Coffee
- Yes
- No
Amount
Soft drink
- Yes
- No
Amount
Tea
- Yes
- No
Amount
High sugar food
- Yes
- No
Amount
Chewing tobacco
- Yes
- No
Amount
Cigarettes
- Yes
- No
Amount
Excessive stress
- Yes
- No
Amount
Review of systems
Check all that applies
Head
- Headaches
- Blurred vision
- Cloudy vision
Hair
- Hair loss
- Dry hair
- Clumps of hair coming out
Cardiovascular
- Water retention
- Cannot tolerate much exercise
- Difficult breathing
- Chest pain while walking
- Heaviness in legs
- Calf muscle cramp often
- Heart pounds easily
- Palpitations
- High blood pressure
- Low blood pressure
Respiratory
- Shortness of breath
- Chronic lung congestion
- Wheezes
- Cough
- Acute congestion
Gastrointestinal
- Constipation
- Diarrhea
- Heart burn
- Abdominal pain
- Certain foods cause ill feeling
- Blood in stool
- Epigastric pain
- Hernia
Urinary
- Frequent Urination
- Burning with urination
- Incontinent issues
Musculoskeletal
- Change in muscle mass
- Joint pain
- Limitation in motion
Dermatological
- Dry skin
- Oily skin
- Acne
Metabolic
- Difficulty gaining weight
- Difficulty losing weight
- Sensitivity to cold
- Wake up craving sweets
- Fatigue
- Feel faint
- Night sweats
- Increased thirst
- Craves sweets
- Weight loss more than 10 lbs in 6 months
- Weight gain more than 10 lbs in 6 months
Psychological
- Rapid mood swings
- Moodiness/ change in mood
- Depression
- Lack of self-esteem
- Anxiety
- Difficulty concentrating
- Short attention span
- Forgetfulness
Sleep
- Difficulty going to sleep
- Difficulty staying asleep
- Wake up frequently
Hours of sleep per night

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Females Only
Females Only
- Bloating and swelling
- Breast tenderness
- Miscarriage
- Vaginal discharge
- Underactive sex drive
- Pelvic soreness
- Menstrual pain
- Insomnia
- Vaginal bumps/sores
- Premenstrual chest discomfort
- Hot flashes
- Night sweats
- Vaginal dryness
- Infertility
- Heavy menstrual bleeding
- Ovarian cysts
- Breast lump
- Irregular period
Date of last menstrual cycle
Date of last pelvic exam and pap smear
Results
Date of last Mammogram
Sexually transmitted diseases
Form of birth control
- None
- IUD
- Diaphragm
- Condom
- Pill
- Sponge
- Foam
- Other
Males Only
Males Only
- Pain with ejaculation
- Difficulty maintaining erection
- Sexual drive underactive
- Premature ejaculation
- Pain in genital area
- Infertility
- Low sperm count
- Discharge from penis
- Rash on penis
- Swelling in groin
- Loss of urine control
- Frequent urination at night
Date of last prostate exam
Results
Last PSA blood level
Do you use Viagra
- Yes
- No
How often
Does it help?
- Yes
- No
- Maybe
Do you use any other medication for sexual function?
- Yes
- No
Please list
Email
This field is for validation purposes and should be left unchanged.

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Monthly Specials

The Enriched Firming Mask is expertly formulated with botanical ingredients to help soothe and improve the visible appearance of elasticity and firmness of the skin.

15% off Reg. Price $38, 15% off

ABHRT-Certification-Seal

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