+1 410 817 1145
Aesthetics@soundwellnessmd.com
8890 Mcdonogh Road, Suite 301, Owings Mills,
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+1 410 817 1145
Aesthetics@soundwellnessmd.com
Facebook
X-twitter
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Assessment form
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Full Name:
*
First
Last
Date of Birth (MM/DD/YYYY)
*
Gender
*
Female
Male
Other
Contact Number
*
Email Address
*
Address
Address Line 1
Address Line 2
City
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District of Columbia
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Texas
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name
*
First
Last
Emergency Contact Phone
Preferred Contact Method
Relationship
*
SECTION 2: HEALTH & MEDICAL BACKGROUND
Primary Care Physician
*
Are you currently under medical care?
*
Yes
No
If yes, please specify
*
Have you had any surgeries in the past 12 months?
*
Yes
No
If yes, please specify
Do you have any of the following conditions? (Check all that apply)
Diabetes
High Blood Pressure
Heart Disease
Thyroid Disorder
Epilepsy
Kidney Disease
Cancer (Past/Present)
Autoimmune
Condition
None of the above
Are you currently pregnant or breastfeeding?
*
Yes
No
Are you taking any medications or supplements?
*
Yes
No
If yes, list them
Do you have any known allergies (medications, food, latex, etc.)?
*
Yes
No
If yes, specify
SECTION 3: LIFESTYLE & WELLNESS
How would you describe your activity level?
*
Sedentary
Lightly Active
Moderately Active
Very Active
How many hours of sleep do you get per night?
*
How would you rate your stress level?
*
Low
Moderate
High
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
Occasionally
No
How many 12-oz glasses of water do you usually drink in a day?
Selected Value:
0
Primary health/wellness goals (select all that apply)
*
Weight Loss
Body Contouring
Skin Rejuvenation
Detox/Wellness
Energy Boost
Anti-Aging
Other (please specify)
SECTION 4: AESTHETIC HISTORY
Have you had any of the following procedures? (Check all that apply)
Laser Lipo
BBL (Non-Surgical)
Facials or Peels
Botox or Fillers
IV Vitamin Therapy
Other
Were you satisfied with previous treatments?
*
Yes
No
If no, please explain
please How is
SECTION 5: CURRENT CONCERNS & GOALS
What specific areas of concern would you like us to address?
*
What is your main motivation for seeking treatment today?
*
Health improvement
Appearance enhancement
Confidence boost
Other
Desired outcome:
*
How soon are you hoping to achieve results?
*
1–3 months
3–6 months
6–12 months
SECTION 6: CONSENT & ACKNOWLEDGMENT
By submitting this form, I confirm that the information provided is true and complete to the best of my knowledge. I understand that this assessment will be used to tailor a personalized treatment plan.
Photo Upload (for treatment evaluation)
Click or drag a file to this area to upload.
photos (for treatment evaluation).
Signature
*
Date
*
Consent
*
I have read and agree to the Clinic’s Privacy Policy (Please view under the "pages" tab to review)
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