Patient Name Date Email Medical and Surgical History Age: Weight : Height: Gender MaleFemale Active wounds* YesNO Active severe or cystic facial acne* YesNO Metal stents in the treatment area* YesNO Implanted electrical devices* YesNO Pregnant or lactating YesNO Migraines YesNO Bell’s palsy YesNO Mechanical or other implants in the treatment area* YesNO Active or local skin disease that may alter wound healing* YesNO Autoimmune disease* YesNO Epilepsy* YesNO Herpes or cold sores* YesNO Diabetes* YesNO Hemorrhagic or bleeding disorders* YesNO Undergone the following cosmetic procedure in the brow or lower face and neck area: Facial skin tightening procedure treatment within the last 1year YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Filler (i.e. juvederm® or Sculptra®) within the last 3-6months YesNO If Yes, Please fill the below information Product name Location treated: Date of last treatment Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months YesNO If Yes, Please fill the below information Product name Location treated: Date of last treatment Ablative resurfacing laser treatment YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Non-ablative resurfacing laser treatment YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Dermabrasion or deep facial peels YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Lipoplasty in the face or neck regions YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Facelift or blepharoplasty or brow lift YesNO If Yes, Please fill the below information Treatment name Location treated: Date of last treatment Are you currently taking the following prescription medications: Accutane within the last 12 months Anticoagulants or antiplatelet drugs Immunosuppressant drugs List all medications or supplements below. Be sure to include all prescription or non-prescription medications. If you are not taking any medications or supplements, please leave them blank: Medication Disease/Reason Dose Frequency Date started Date last taken HIFU CONSULT RECORD Every patient is different, the clinical factors listed below are intended to assist your clinician in forecasting your clinical response to HIFU treatment. Please score each clinical factor listed below. Upon examination of your responses, your physician will discuss your options for achieving optimum results with HIFU treatment. Age <35 y/o35-49 y/o50-64 y/o65+ y/o Smoking History Never smokedEx-smokerLight smokerHeavy smoker Health No health issuesMinor health issuesChronic health issues Sun exposure Never use sunscreenOccasionally use sunscreenAlways use sunscreen Clinical response Factors- Upper face and neck: Check the appropriate box None Mild Moderate Severe Skin Laxity: Excess skin or hooding on the eyelid; eye droopiness Volume: Presence of fat deposits under eyes; infra-orbital puffiness Skin Quality: Fine lines, creepiness/wrinkling, and/or poor elasticity Clinical response Factors- Lower face and neck: Check the appropriate box None Mild Moderate Severe Volume: Presence of fat deposits under eyes; infra-orbital puffiness Skin Quality: Fine lines, creepiness/wrinkling, and/or poor elasticity Clinical response Factors- Body: Check the appropriate box None Mild Moderate Severe Volume: Presence of fat deposits under eyes; infra-orbital puffiness Skin Quality: Fine lines, creepiness/wrinkling, and/or poor elasticity What are your treatment Goals Additional findings: Patient Signature [signature* PatientSignature] submit
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