Health History Questionnaire Page 5
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at
. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Date of Birth
SKIN ASSESSMENT: Check all that apply.
Fine lines/ wrinkles
Loss of glow/vitality
Pale, sallow appearance
Loss of skin tone
Have you seen anyone, i.e., dermatologist, plastic surgeon, spa facility?
If so please provide approximate date(s) of service.
Any other comments or concerns:
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