Liu Plastic Surgery CONFIDENTIAL HEALTH QUESTIONNAIRE (INJECTABLE)

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Liu Plastic Surgery Aesthetic and Reconstructive Plastic Surgery

Personal Information

Patient Name: ________________________________________________________ Date: ____________________

Date of Birth: _________________________Age: ____________ Height: ____________ Weight: ______________

Address: ______________________________________________________________________________________

City: ______________________________________________________ State:________ Zip:_________________

Home Phone: ___________________________________ Mobile Phone: __________________________________

E-mail Address: ____________________________________ Best Way to Reach You: Home Mobile E-mail

Would you like to be notified of Special Events and Offers? Yes No

How did you hear about us? Our Website Facebook RealSelf Internet Search Yelp

Friend/Family__________________________ Other__________________________

Main Concern(s) of today’s consultation is:__________________________________________________________

Medical History

Allergies

Agent Reaction

Medication(s) None

Tape(s) (type) None

Latex(s) None

Current Medications/Supplements (Please list ONLY the medications you currently take)

Medication Dosage Medication Dosage Medication Dosage

Health Supplements/Herbs/OTC Medications [Please list all substances that you take (e.g. fish oil, ginseng, etc.)]

Do you use St John’s Wort? Yes No Do you take Ginseng? Yes No

Do you use any diet pills (ex. phentermine)?

Yes No Do you take Omega-3 (fish oil) or Vit-E?

Yes No

Do you use any non-prescription medication or drugs not already listed? Yes No

If yes, please list:

Liu Plastic Surgery CONFIDENTIAL HEALTH QUESTIONNAIRE (INJECTABLE)

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Medical History (Please list any medical problems you may have)

Injectables (Complete ONLY if here for injectable procedure)

Have you taken aspirin, anti-inflammatory medications (NSAIDs) or blood thinners (Coumadin, Warfarin, Lovenox, etc.) within the past two weeks? If yes, please list:

Have you experienced a reaction to a transfusion??

Yes No Prolonged bleeding when cut and/or family history?

Yes No

Have you ever had prolonged bleeding with surgical procedures, such as tonsillectomy?

Yes No Have you ever had spontaneous nosebleeds lasting more than 10 minutes?

Yes No

Do you often get prolonged bleeding from trivial wounds or bruising with no apparent trauma?

Yes No Do you have a blood relative with a bleed disorder like hemophilia or von Willebrand disease?

Yes No

Botox (Complete ONLY if here for the Botox procedure)

Do you have any neuromuscular disorders (myasthenia gravis, Lambert-Eaton syndrome)? Yes No

Chemical Peels/Lasers (Complete ONLY if here for chemical peel or laser procedure

Have you ever had a chemical peel or laser treatment to the face? Yes No If yes, Type: __________________ Date: _______________________

Have you ever had HYPOpigmentation (loss of color) as a result of the treatment?

Yes No Have you ever had HYPERpigmentation (increase in color) as a result of the treatment?

Yes No

Have you ever had “fever or lip blisters” as a result of treatment around your lips?

Yes No Have you ever taken antiviral medications (before or after) treatment around your lips?

Yes No

Sun Exposure (Complete ONLY if here for chemical peel or laser procedure

How would you rate your daily sun-exposure? (Check ONLY one)

Outdoors - Constantly under the sun

Outdoors - more often than not

Outside occasionally, mainly inside

Inside most of the time, rarely see the sun

How would you rate your daily sun-protection regimen? (Check ONLY one)

Sun protection every day, always try to shield myself from the sun

Sun protection every day, but don’t mind being out in the sun

Sun protection occasionally

Rare or never wear sun protection

Women’s Health

Is there any chance you could be pregnant?

Yes No

Are you currently breastfeeding? Yes No

Liu Plastic Surgery CONFIDENTIAL HEALTH QUESTIONNAIRE (INJECTABLE)

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Cosmetic/Skincare Information

Are there any additional cosmetic procedures or products of interest to you (Please check all that apply):

InMode FaceTite and BodyTite radio-frequency skin tightening

Viveve by GeneveveTM

non-invasive vaginal rejuvenation and tightening

Coolsculpting® non-invasive fat reduction CellfinaTM

in-office cellulite treatment

Ultherapy® non-invasive skin tightening Microneedling

Juvederm® / Restylane® / Belotero® / Radiesse®/ Sculptra® injectable filler

Platelet Rich Plasma (PRP) for skin enhancement, facial rejuvenation and hair loss

Botox® / Dysport® / Xeomin® Sclerotherapy for leg veins

Aesthetician facial treatments / Chemical peels / Micro-dermabrasion

Skin care advice / Skin care products / Eyelash growth and enhancement products

Aesthetic (Cosmetic) Plastic Surgery procedures Fat grafting (Face, Breast and Buttocks)

Other; please specify: Hydrafacial

Specific concerns regarding your skin/appearance (Please check all that apply):

Fine Lines/Wrinkles Rosacea Shiny Areas Dark Circles

Dry Skin/Dry Patches Acne Dry Lips Puffy Eyes Eyelashes

Dark Spots/ Hyperpigmentation Blotchiness / Discoloration

Select the areas or procedures that are of interest to you (Please check all that apply)

Face and/or Neck Nose Breast Eyes Body Contouring

Other; please specify:

Select the type of skin you believe you have:

Dry Normal Oily Blemished

Dry all over, tight, easily irritated, sun-damaged, loss of softness, normal in the t-zone

Normal in the t-zone, normal on the sides of the face

Oily in the t-zone, normal to oily on the sides of the face, prone to breakouts

Oily all over with frequent problematic breakouts

Skincare

Do you use a regular skincare routine? Yes No

If so, list the products you currently use on a daily basis:

How often do you have facials? Never 1-4 times a year Once a month More than once a month

Have you ever had a cosmetic procedure? Yes No

If so, please specify the type of procedure, surgeon, and date of procedure.

I certify that the above is true to the best of my knowledge. I acknowledge the Liu Plastic Surgery privacy policy has been made available to me. By signing below I approve to receive information from Liu Plastic Surgery. Patient Name:_________________________________________________________Date:____________________ Patient Signature:_______________________________________________________________________________