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Check the appropriate box next to any condition for which you have ever been treated Acne - Are you currently on Accutane? Yes No OR have you used it in the past? Yes No 1. Are you currently being treated for a condition not listed? If yes, please specify.
___________________________________________________________________________________________________ 2. Are you currently taking any medications or herbal supplements? If yes, please specify.
___________________________________________________________________________________________________ 3. Do you have any allergies? If yes, please specify.
___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 5. Have you ever used or are you using Accutane? If yes, please specify when.
___________________________________________________________________________________________________ 6. How many diet/exercise regiments have you tried in the last 5 years? ___________________________________________________________________________________________________ 7. Have you ever had any laser treatments in the last six months? If yes, please specify.
___________________________________________________________________________________________________ 8. Is there any family history of Diabetes, Heart Disease or Obesity that you are aware of? ___________________________________________________________________________________________________ 9. Do you have any metal implants? If yes, please specify.
___________________________________________________________________________________________________ 10. Is your doctor monitoring you for any medical conditions? ___________________________________________________________________________________________________ 11. Do you have any particular skin problems or sensitivities? ___________________________________________________________________________________________________ 12. Have you ever been treated by an endocrinologist? If yes, please specify the condition.
___________________________________________________________________________________________________ 13. Have you or are you currently undergoing chemotherapy treatments? ___________________________________________________________________________________________________ 14. Have you had any surgical or cosmetic procedures in the last year? If yes, please specify.
___________________________________________________________________________________________________ 15. For woman, when was your last menstrual cycle? ___________________________________________________________________________________________________ 16. Are you currently pregnant? Or unsure? If yes, please specify.
___________________________________________________________________________________________________ 17. Please write the name, address, fax and phone number of your primary care Physician.
___________________________________________________________________________________________________ Please sign below to indicate all the information on this form is accurate and complete Signature:
White – administration Yellow – patient file

Source: http://www.zeronacanada.ca/phocadownloadpap/forms/03-health-history.pdf