About this template
The Aesthetic Medical History Form template provides a comprehensive and organized way for medical spas, dermatology clinics, and cosmetic practitioners to collect essential patient health information prior to aesthetic procedures. Gathering detailed background data—such as known allergies, current medications, previous treatments, and underlying health conditions—is a vital part of the pre-treatment process.
By identifying potential contraindications for procedures like injectables, laser treatments, or chemical peels, this form helps practitioners evaluate health risks and ensure patient safety. It also captures patient goals and expectations, establishing a reliable baseline for customized treatment plans and effective follow-up care.
Doc2Form allows clinics to instantly convert documents or build out digital workflows to collect this critical health information securely. With a mobile-friendly design, patients can complete their intake documentation ahead of time from any device, streamlining clinic operations and allowing practitioners to focus entirely on client care.
Key features
- Capture comprehensive medical history and lifestyle factors in one step.
- Screen for contraindications like allergies, pregnancy, and recent medications.
- Mobile-friendly design for easy completion on smartphones and tablets.
- Instantly organized responses ready for review before appointments.
- Streamline pre-procedure intake to save time in the clinic.
Use cases
New patient intake at medical spas and aesthetic clinics.
Pre-treatment screening before laser therapy or chemical peels.
Recording medical conditions and current skincare regimens prior to i…
Recording medical conditions and current skincare regimens prior to injectables.
Updating annual health and medication records for repeat clients.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Phone Number (Short answer)Provide the best phone number to reach you.
- Email Address (Short answer)Where we can send appointment confirmations and care instructions.
- Date of Birth (Date)Enter your date of birth.
- Emergency Contact Name and Phone (Short answer)Provide the name and phone number of someone we can contact in an emergency.
- Allergies (Paragraph)List any known allergies to medications, food, latex, or topical products.
- Are you currently pregnant or breastfeeding? (Multiple choice)Certain aesthetic treatments are contraindicated during pregnancy and lactation.
- Do you have any chronic medical conditions? (Paragraph)Select all that apply or describe below.
- Current Medications and Supplements (Paragraph)List any prescription medications, over-the-counter drugs, or herbal supplements you currently take.
- Recent Cosmetic Treatments (Paragraph)Have you had any fillers, botulinum toxin, chemical peels, or laser treatments in the past 6 months? Please describe details and dates.
- Patient Acknowledgment (Paragraph)Please paste a link to your signed consent document or type your full legal name here to confirm your information is accurate.
FAQ
What is the purpose of this aesthetic medical history form?
It helps aesthetic practitioners gather crucial health data—including medications, allergies, and past procedures—to identify potential risks and ensure treatments are safe and appropriate for the patient.
Can I customize the questions on this Google Form template?
Yes. Once the template is in your Google Drive, you can easily add, remove, or edit any questions to match your clinic's specific procedural requirements.
Is this form mobile-friendly for my patients?
Google Forms automatically formats your questionnaire for optimal viewing and completion on smartphones, tablets, and desktop computers.
How do I share this form with clients before their appointment?
You can easily send the form link via email or text message, or embed it directly on your practice website so clients can complete it ahead of time.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.