Home
Cosmetic Treatments
Injectables
Botox and Xeomin Cosmetic
Dermal Fillers
PRP for Face – Vampire Facial
PRP for Under Eye
Purasomes
Skin Rejuvenation
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Microneedling for Skin Rejuvenation & Acne Scars
Medical-Grade Peels & Jessner’s Peel
Bela Facials
Excessive Pigmentation Treatment
Hair & Veins
PRP for Hair Loss
Spider Vein Treatment with Sclerotherapy
Vein Treatments for Spider Veins, Varicose Veins & Leg Health
Women’s Health
Healthy Menopause
Skin Concerns
Aging & Wrinkles
Botox and Xeomin Cosmetic
Dermal Fillers
PRP for Face – Vampire Facial
Microneedling for Skin Rejuvenation & Acne Scars
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Pigmentation & Sun Damage
Excessive Pigmentation Treatment
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Medical-Grade Peels & Jessner’s Peel
Acne & Acne Scars
How to Stop Acne: Customized Acne Treatment for Clear Skin
Microneedling for Skin Rejuvenation & Acne Scars
Medical-Grade Peels & Jessner’s Peel
Hair Loss
PRP for Hair Loss
Purasomes
Spider Veins
Vein Treatments for Spider Veins, Varicose Veins & Leg Health
Spider Vein Treatment with Sclerotherapy
Skin Cancer Prevention
Photodynamic Therapy
Mohs Micrographic Surgery
Medical Dermatology
Skin Cancer & Surgery
Mohs Micrographic Surgery
Photodynamic Therapy
Mole and Skin Tag Removal: Everything You Need to Know
Login
Medical Botox Treatments
Botox® for Migraines
Botox® for Excessive Sweating
Shop
Medical-Grade Skincare
Shop All Products
SkinCeuticals
ZO Skin Health
Colorescience
Neocutis
About
Our Team
Dr. Lili Nasseri, Expert Injector
Dr. Eiman Nasseri, Dermatologist New Westminster, BC
Our Loyalty Program
Blog
Contact
Buy 2 areas of Xeomin Cosmetic, receive a complimentary area of your choice.
Book Now
.
Book Now
Home
Cosmetic Treatments
Injectables
Botox and Xeomin Cosmetic
Dermal Fillers
PRP for Face – Vampire Facial
PRP for Under Eye
Purasomes
Skin Rejuvenation
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Microneedling for Skin Rejuvenation & Acne Scars
Medical-Grade Peels & Jessner’s Peel
Bela Facials
Excessive Pigmentation Treatment
Hair & Veins
PRP for Hair Loss
Spider Vein Treatment with Sclerotherapy
Vein Treatments for Spider Veins, Varicose Veins & Leg Health
Women’s Health
Healthy Menopause
Skin Concerns
Aging & Wrinkles
Botox and Xeomin Cosmetic
Dermal Fillers
PRP for Face – Vampire Facial
Microneedling for Skin Rejuvenation & Acne Scars
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Pigmentation & Sun Damage
Excessive Pigmentation Treatment
IPL Skin Rejuvenation for Redness, Pigmentation & Sun Damage
Medical-Grade Peels & Jessner’s Peel
Acne & Acne Scars
How to Stop Acne: Customized Acne Treatment for Clear Skin
Microneedling for Skin Rejuvenation & Acne Scars
Medical-Grade Peels & Jessner’s Peel
Hair Loss
PRP for Hair Loss
Purasomes
Spider Veins
Vein Treatments for Spider Veins, Varicose Veins & Leg Health
Spider Vein Treatment with Sclerotherapy
Skin Cancer Prevention
Photodynamic Therapy
Mohs Micrographic Surgery
Medical Dermatology
Skin Cancer & Surgery
Mohs Micrographic Surgery
Photodynamic Therapy
Mole and Skin Tag Removal: Everything You Need to Know
Login
Medical Botox Treatments
Botox® for Migraines
Botox® for Excessive Sweating
Shop
Medical-Grade Skincare
Shop All Products
SkinCeuticals
ZO Skin Health
Colorescience
Neocutis
About
Our Team
Dr. Lili Nasseri, Expert Injector
Dr. Eiman Nasseri, Dermatologist New Westminster, BC
Our Loyalty Program
Blog
Contact
Book Now
Patient Health Questionnaire
First Name
Last Name
Emergency Contact
Next of Kin
Relationship to Patient
Contact Telephone
Power of Attorney
Relationship to Patient
Contact Telephone
Dermatologist
Family Doctor
Clinic
Fax
Employment
Retired
Disability
Not Working
Student
Working
If Working, Job title and duties
Exact location of lesion
Duration of Lesion
< 1 Yr
1-5 Yrs
> 5 Yrs
Previous treatment other than the biopsy
None
Previous Surgery
Burning or Scraping
Liquid Nitrogen
Chemo Cream
List all medications/drugs/vitamins/prescription creams you are currently using (including nonJprescription medications like Aspirin, Ibuprofen). It is not necessary to provide dosages.
Write None if not taking any medication.
Medication List
Are you on Coumadin or Warfarin
No
Yes
If Yes, Provide latest INR
Alcohol
No
Yes
Alcohol Amount
Alcohol Frequency
Nicotine
No
Yes
Nicotine Type
Nicotine Amount
Nicotine Frequency
Height (m)
Weight (kg)
BMI (m/kg2)
Do you have or have you ever had any of the following conditions?
Previous skin cancer
No
Yes
Which type i.e. Basal cell, Squamous cell, Melanoma
Other cancer (e.g. lymphoma or leukemia)
No
Yes
Which type
Previous radiation therapy
No
Yes
Seizures
No
Yes
Epilepsy
No
Yes
Fainting
No
Yes
Fear of needles
No
Yes
Arrhythmia
No
Yes
Pacemaker
No
Yes
Defibrillator
No
Yes
Heart valve replacement
No
Yes
Heart infection
No
Yes
Heart stents
No
Yes
Heart defect
No
Yes
Heart blockage
No
Yes
Lung / breathing problems requiring oxygen therapy
No
Yes
Liver disease (e.g. hepatitis)
No
Yes
Kidney disease (e.g. dialysis)
No
Yes
High blood pressure
No
Yes
Average value
Diabetes
No
Yes
Organ transplant
No
Yes
Body area
Joint replacement / infection (e.g. hip, knee)
No
Yes
Date
Difficulty lying on your back / wheelchair / walker
No
Yes
Allergies (e.g. Penicillin, Clindamycin, Lidocaine, Xylocaine, Tylenol, Codeine, Latex, Band-Aids)
No
Yes
Product(s)
Reaction(s)
Allergy tested / EpiPen
Infection (e.g. HIV, Hepatitis, MRSA, VRE)
No
Yes
Infection Type
Cold sores
No
Yes
Genital herpes
No
Yes
Are you currently pregnant
No
Yes
Any other health problems
No
Yes
Other Health Problems
Submit
