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Skin & Sculpt Medical Spa
About Us
Our Team
Photo Gallery
Testimonials
Skin Care
Facials Customized for You
Dermaplaning
Microdermabrasion
Laser Treatments
Skin Pen
Teeth Whitening
Chemical Peels
Diamond Glow
Secret RF Microneedling
Cosmetic Procedures
BOTOX in Knoxville
Xeomin
JUVÉDERM®
KYBELLA®
Body
CoolSculpting
What Is CoolSculpting In Knoxville TN?
What to expect
How does CoolSculpting work?
CoolSculpting FAQ
CoolSculpting Before and After
CoolSculpting Inquiry
Weight Management
Phentermine
B Complex Plus Lipotropics
Hair Growth
Products
ALASTIN Skincare® Information
Elta MD®
LATISSE®
PCA SKIN®
SkinMedica
Upneeq
Specials
Monthly Specials
Birthday Specials
Shop
Cart
Gift Card Balance
Forms
Blog
Contact
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About Us
Our Team
Photo Gallery
Testimonials
Skin Care
Facials Customized for You
Dermaplaning
Microdermabrasion
Laser Treatments
Skin Pen
Teeth Whitening
Chemical Peels
Diamond Glow
Secret RF Microneedling
Cosmetic Procedures
BOTOX in Knoxville
Xeomin
JUVÉDERM®
KYBELLA®
Body
CoolSculpting
What Is CoolSculpting In Knoxville TN?
What to expect
How does CoolSculpting work?
CoolSculpting FAQ
CoolSculpting Before and After
CoolSculpting Inquiry
Weight Management
Phentermine
B Complex Plus Lipotropics
Hair Growth
Products
ALASTIN Skincare® Information
Elta MD®
LATISSE®
PCA SKIN®
SkinMedica
Upneeq
Specials
Monthly Specials
Birthday Specials
Shop
Cart
Gift Card Balance
Forms
Blog
Contact
Patient Personal Health History
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Medications (Name/Frequency)
List all prescription and over the counter medications, herbs and vitamins you take on a regular basis.
Allergies
List names of medicines or foods that have resulted in an unfavorable reaction. State reaction.
Latex, insect bites, environmental
Personal Health History
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Acne
Alcohol/substance abuse
Allergies
ADD/ADHD
Anxiety or depression
Anemia
Asthma
Bleeding/clotting disorder
Chrons/Ulcerative Colitis
Kidney stones
Rheumatoid Arthritis
Seizures
Systemic Lupus Erythematous
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Check all that apply
Diabetes
Eating disorders
Eczema or psoriasis
Headaches/ Migraines
Heart disease
High Blood Pressure
Thyroid disorder
Intestinal Disorders
Ulcers
HIV/AIDS
Polycyctic Ovary
Herpes Simplex
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Pregnancy
Psychological Disorders
Bipolar Disorders
Obsessive Compulsive Disorder
Cardiac Arrhythmia
High Cholestorial
Chronic Fatigue Syndrome
+TB test
Cancer or Tumor
Multiple Sclerosis
Myasthenia Gravis
Smoker Present/Past
Sexually Transmitted Infection
Surgical, Hospitalizations, Trauma History
Please list the type and date of any surgeries, hospitalizations, or serious injuries you have had.
Family History
Heart Disease
Hypertension
Alcohol/Drug Abuse
Stroke
Diabetes
Mental Illness
Cancer
High Cholesterol
Eating Disorder
To the best of my knowledge, the above information is true. I have not knowingly withheld any information about my past or present health condition.
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