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Medical History Spanish
Services
Body Sculpting
BodySculp
Non-Surgical Buttocks Lift
Mesotherapy
BodyTone
Injectables
Dermal Fillers
Botox® / Xeomin®
Kybella®
Daxxify®
Advanced Skin Tightening
Ultherapy®: Body and Face
PDO Threads: Body and Face
Silhouette InstaLift™
Advanced Skin Rejuvenation
SkinPen® Microneedling
IPL Skin Resurfacing
Vampire Facelift
PRP Microneedling
PiXel8
Chemical Peel
Retinol & Skin Care
Erbium Laser Resurfacing
Tattoo Removal
Wellness
B12 Vitamin Injections
Weight Management Medication
Upneeq®
Laser Vein Reduction
Semaglutide
Hair
Laser Hair Removal
Latisse®
Conditions
Face
Acne
Acne Scars / Scar Treatment
Aging
Cheek Hollows
Double Chin
Dry Skin
Eyebrow Lift
Frown Lines
Gummy Smile
Jowls
Smile Lines
Sun Spots / Pigmentation
Thin Lips
Under Eye Hollows
Wrinkles
Body
Acne Scars / Scar Treatment
Aging
Aging Hands
Cellulite
Excessive Fat
Facial Hair
Hair Loss / Thinning
Hyperhidrosis / Sweating
Muscle Tone
Sagging Skin
Scars
Stretch Marks
Unwanted Hair
Unwanted Tattoos
Veins
About
Contact Us
Meet The Team
Blog
Location
For Patients
Book Your Appointment
Medical History
Medical History Spanish
Procedure Informed Consent
Procedure Informed Consent Spanish
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Medical History Spanish
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Medical History Spanish
Primer Nombre*
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Apellido*
(Required)
E-mail*
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HISTORIA CLÍNICA
HISTORIA CLÍNICA
Medical History
(Required)
ninguno
ansiedad
Coágulos de sangre
Hepatitis C
hipertensión
Embarazadas o lactantes
Infarto de miocardio
Trastorno convulsivo
Enfermedad tiroidea
Otro
ACTIVIDAD DE EJERCICIO
ACTIVIDAD DE EJERCICIO
(Required)
moderado
vigoroso
sedentario
CONSUMO DE TABACO
CONSUMO DE TABACO
(Required)
No
diario
semanal
menos
Usuario anterior
CONSUMO DE ALCOHOL
CONSUMO DE ALCOHOL
(Required)
No
diario
semanal
menos
Usuario anterior
¿ESTÁ TOMANDO ACTUALMENTE SUPLEMENTOS O MEDICAMENTOS RECETADOS?
¿ESTÁ TOMANDO ACTUALMENTE SUPLEMENTOS O MEDICAMENTOS RECETADOS?
(Required)
Sí.
No tomo ningún medicamento.
Indique cualquier medicamento
(Required)
¿ES ALÉRGICO A ALGÚN MEDICAMENTO?
¿ES ALÉRGICO A ALGÚN MEDICAMENTO?
(Required)
No
Sí. Por favor, enumere
Otro:
enumere cualquier medicamento
(Required)
¿Es alérgico a algún medicamento?
(Required)
¿HAS TENIDO ALGUNA CIRUGÍA EN LOS ÚLTIMOS 5 AÑOS?
¿HAS TENIDO ALGUNA CIRUGÍA EN LOS ÚLTIMOS 5 AÑOS?
(Required)
Sí
No
Otro
¿Ha tenido alguna cirugía en los últimos 5 años?
(Required)
HISTORIA QUIRÚRGICA PREVIA
HISTORIA QUIRÚRGICA PREVIA
(Required)
ninguno
Bypass gástrico
Ligadura de trompas bilaterales
histerectomía
TAH/BSO
Otro:
MEDICAMENTOS POR ALERGIAS*
MEDICAMENTOS POR ALERGIAS*
(Required)
Sí
No
Otro
Medicamentos por alergias*
(Required)
FIRMA DEL PACIENTE/RESPONSABLE
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Date
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MM slash DD slash YYYY
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