Regional Approach to Aesthetic Rejuvenation in .NET

Drawing Quick Response Code in .NET Regional Approach to Aesthetic Rejuvenation

Figure 11 A C (Continued)

Are you under a doctor s care Yes No For what condition Reason for today s visit Have you ever had dental anesthesia Yes No Novicaine Any problem Have you ever taken a course of Accutane (Isotretinoin) Yes If so, when Do you have a history of hypertrophic scars/keloids Yes Do you have a history of cold sores Yes If yes, please provide details Pregnancy: Are you now pregnant Yes Number or pregnancies Are you sexually active Yes

List any serious or chronic illness: 1 3 2 4 List all previous surgery: 1 2 Social History: Do you drink alcohol Do you use IV drugs If YES what Do you smoke Yes Occupation Skin: Have you ever had skin cancer Has anyone in your family ever had skin cancer Do you have a history of any speci c skin disease If Yes Do you have problems with healing Do you develop keloids (scars) after surgery Do you bleed easily

3 4

5 6

Do you have (circle): Dentures Capped teeth Bridges Loose teeth Chipped teeth Contact lenses Glasses Hearing aid Other prosthetic devices: Diseased gums

Important medical conditions: Have you ever had or received treatment for any of the following (Please circle)

Hepatitis, jaundice, cirrhosis or liver disease Asthma, TB, pneumonia Bronchitis, emphysema or chest disease Heart attack, angina, palpitations, chest pain Irregular heart beats or heart murmur Shortness of breath or fainting spells Mitral valve prolaps/bacterial endocarditis Rheumatic fever or congenital heart disease High or low blood pressure Kidney failure, kidney or prostate problems Dialysis Excessive hunger or thirst Amputation Stomach absorptive disorder Nausea, vomiting, diarrhea or yeast infection when taking antibiotics Migraines, headaches or chronic head pain Lupus, scleroderma or autoimmune disease Phlebitis, blood clots or varicose veins Stroke, Bell s palsy or neurological problems Shingles, cold sores or fever blisters Abnormal or excessive bleeding Hives, rashes or skin disease Diabetes or abnormal blood sugar Adverse or unusual reaction to anesthesia Immune disorder such as vitiligo Other medical conditions Explain: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No No Blood transfusion HIV or AIDS Anemia or blood disorder Chronic or recent cough Wheezing Alcohol abuse or alcoholism Drug abuse or drug addictions Thyroid problems Venereal disease Anaphylaxis Stomach ulcers Arthritis/joint deformity Arthralgia Limited motion Arti cial joint Epilepsy or seizures Anorexia or bulimia Nervous breakdown Personality disorder Psychological/emotional problems Recent weight gain or loss Anxiety or panic attacks X-ray treatments Radiation therapy Pacemaker Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No No

Drugs and medicines: Have you, within the last 6 months, taken any of the following (Please circle)

Accutane Homeopathic or herbal medicines Stimulants, appetite suppressants, diet pills Sedatives, tranquilizers or sleeping pills Antidepressants, antipsycotics or nerve pills Cortisone, prednisone or ACTH Heart medication, Digitalis, Lanoxin Blood pressure medication Steroids or body building drugs Headache or migraine medications Insulin, Orinase or similar drugs Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No Anticoagulants or blood thinners Pain pills Birth control pills Phen-Phen or Redux Recreational or illegal drugs Asthma meds, inhalers, etc Diuretics or water pills Nitroglycerine Seizure medication Antibiotics Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

Figure 12 (Continued)