Home
About Us
Our Loyalty Program
Our Team
Dr. Eiman Nasseri
Dr. Lili Nasseri
Services
Bela Facials
Botox® Cosmetic & Xeomin
Botox® for Excessive Sweating
Botox® for Migraines
Dermal Fillers
Healthy Menopause
HELP Pigment Program
IPL & Skin Rejuvenation
Medical-Grade Peels
Microneedling for Skin Rejuvenation & Acne Scars
Mohs Surgery
Mole and Skin Tag Removal
PDT For Skin Cancer Prevention
PRP for Hair Loss
PRP for Under Eye
PRP for Face
Purasomes
How to Stop Acne: Customized Acne Treatment for Clear Skin
Spider Vein Treatment with Sclerotherapy
Shop
Login
Contact Us
Book Now
Home
About Us
Our Loyalty Program
Our Team
Dr. Eiman Nasseri
Dr. Lili Nasseri
Services
Bela Facials
Botox® Cosmetic & Xeomin
Botox® for Excessive Sweating
Botox® for Migraines
Dermal Fillers
Healthy Menopause
HELP Pigment Program
IPL & Skin Rejuvenation
Medical-Grade Peels
Microneedling for Skin Rejuvenation & Acne Scars
Mohs Surgery
Mole and Skin Tag Removal
PDT For Skin Cancer Prevention
PRP for Hair Loss
PRP for Under Eye
PRP for Face
Purasomes
How to Stop Acne: Customized Acne Treatment for Clear Skin
Spider Vein Treatment with Sclerotherapy
Shop
Login
Contact Us
Book Now
Patient Health Questionnaire
First Name
Last Name
Emergency Contact
Next of Kin
Relationship to Patient
Contact Telephone
Power of Attorney
Relationship to Patient
Contact Telephone
Dermatologist
Family Doctor
Clinic
Fax
Employment
Retired
Disability
Not Working
Student
Working
If Working, Job title and duties
Exact location of lesion
Duration of Lesion
< 1 Yr
1-5 Yrs
> 5 Yrs
Previous treatment other than the biopsy
None
Previous Surgery
Burning or Scraping
Liquid Nitrogen
Chemo Cream
List all medications/drugs/vitamins/prescription creams you are currently using (including nonJprescription medications like Aspirin, Ibuprofen). It is not necessary to provide dosages.
Write None if not taking any medication.
Medication List
Are you on Coumadin or Warfarin
No
Yes
If Yes, Provide latest INR
Alcohol
No
Yes
Alcohol Amount
Alcohol Frequency
Nicotine
No
Yes
Nicotine Type
Nicotine Amount
Nicotine Frequency
Height (m)
Weight (kg)
BMI (m/kg2)
Do you have or have you ever had any of the following conditions?
Previous skin cancer
No
Yes
Which type i.e. Basal cell, Squamous cell, Melanoma
Other cancer (e.g. lymphoma or leukemia)
No
Yes
Which type
Previous radiation therapy
No
Yes
Seizures
No
Yes
Epilepsy
No
Yes
Fainting
No
Yes
Fear of needles
No
Yes
Arrhythmia
No
Yes
Pacemaker
No
Yes
Defibrillator
No
Yes
Heart valve replacement
No
Yes
Heart infection
No
Yes
Heart stents
No
Yes
Heart defect
No
Yes
Heart blockage
No
Yes
Lung / breathing problems requiring oxygen therapy
No
Yes
Liver disease (e.g. hepatitis)
No
Yes
Kidney disease (e.g. dialysis)
No
Yes
High blood pressure
No
Yes
Average value
Diabetes
No
Yes
Organ transplant
No
Yes
Body area
Joint replacement / infection (e.g. hip, knee)
No
Yes
Date
Difficulty lying on your back / wheelchair / walker
No
Yes
Allergies (e.g. Penicillin, Clindamycin, Lidocaine, Xylocaine, Tylenol, Codeine, Latex, Band-Aids)
No
Yes
Product(s)
Reaction(s)
Allergy tested / EpiPen
Infection (e.g. HIV, Hepatitis, MRSA, VRE)
No
Yes
Infection Type
Cold sores
No
Yes
Genital herpes
No
Yes
Are you currently pregnant
No
Yes
Any other health problems
No
Yes
Other Health Problems
Submit
