(908) 317-9922
854 Mountain Ave, Mountainside, NJ, 07092
(908) 317-9922
854 Mountain Ave,
Mountainside, NJ, 07092
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Medical Aesthetics Questionnaire
Name*
Age*
Referred By*
What is the main problem that brings you in?*
Do you currently have any of the following medical problems?
Diabetes
Yes
No
Heart Disease
Yes
No
Thrombophlebitis
Yes
No
Epilepsy
Yes
No
Lung Disease
Yes
No
Hay fever or Asthma
Yes
No
Tuberculosis
Yes
No
High Blood Pressure
Yes
No
Rheumatic Fever
Yes
No
Blood Disease
Yes
No
Liver Disease
Yes
No
Cancer
Yes
No
Gonorrhea, Syphilis, PID
Yes
No
Migraine headaches
Yes
No
Gastro-Intestinal Disease
Yes
No
Have you, your family, your husband, or you husband's family ever had any:
Metabolic Disorders (i.e., disease where chemicals are missing from the body)
Yes
No
Chromosomal Disease (i.e., Down's Syndrome or Monopolism)
Yes
No
Genetic Disease (i.e., Spina Bifida, Anencephaly or Meningomyelocele
Yes
No
Defects in the Nervous System
Yes
No
Does anyone in you immediate family currently have or have they had any of the medical problems listed below?
Cancer
Yes
No
Tuberculosis
Yes
No
Diabetes
Yes
No
Heart Trouble
Yes
No
Stroke
Yes
No
High Blood Pressure
Yes
No
Epilepsy
Yes
No
High Cholesterol
Yes
No
Have you had any surgical procedures for the following?
Tonsils
Yes
No
Breasts
Yes
No
Thyroid
Yes
No
Appendix
Yes
No
Stomach
Yes
No
Cesarean Section
Yes
No
Hernia
Yes
No
Gall Bladder
Yes
No
Tubes
Yes
No
Hysterectomy
Yes
No
Varicose Veins
Yes
No
Ovaries
Yes
No
Have you ever had blood transfusions or plasma?
Yes
No
Are you currently on any medications
Yes
No
Are you allergic to anything
Yes
No
Do you smoke?
Yes
No
Do you drink coffee
Yes
No
How old were you when your periods started?*
Are your periods regular?*
What is the length of time between the first day of one period and the first day of the next period?*
How many days does your period last?*
How heavy is your mensural flow?
Age*
Age*
Age*
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