4343 Shallowford Rd #150, Marietta,GA 30062

VIRTUAL CONSULT

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About Dr. Kelley
Lean Body Program
- Semaglutide
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Oshot l Feminine Rejuv
Procedures
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4343 Shallowford Rd #150, Marietta,GA 30062

VIRTUAL CONSULT

Home Page
About Dr. Kelley
Lean Body Program
- Semaglutide
Wellness
Oshot l Feminine Rejuv
Procedures
Testimonials
Pricing

Home Page
About Dr. Kelley
Lean Body Program
- Semaglutide
Wellness
Oshot l Feminine Rejuv
Procedures
Testimonials
Pricing

O shot history

Home>O shot history

General Information

Date *
Name * First Last
Home Phone
Cell Phone
Can we text you?
YesNo
Email
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Birthdate MM-Date-Year
Name for emergency
Phone for emergency
How did you hear about us?

General Medical Heath Questions:

Please list any medical problems:
Are you under the care of another physician for any medical condition?
YesNo
If yes, what for?
Medications
Supplements
Do you have any drug allergies?
YesNo
If yes, what are you allergic to?
Do you smoke cigarettes?
YesNo
How much?
Do you drink alcohol?
YesNo
How much?
Please place an X if you have ever had any of these conditions
Fever blistersMigraines headachesHeart troubleIrregular heartbeatAbnormal EKGHigh blood pressureAsthmaIndigestion or ulcersHepatitis or liver problemsKidney problemsSeizures or neurological problemsPsychiatricDiabetesThyroid problemsLight-headednessBleeding tendencyBlood clots lungs, legs or bodyArthritis or back troubleExcessive scarring or abnormal healingRecurrent infectionsReactions to anesthesiaEasy bruisingOther
Please list any prior surgeries?
Have you had a vaginal delivery?
YesNo
If yes, what was the weight of the baby?
What would you like to change?
Sexual enjoymentImprove orgasmBladder leakingVaginal drynessLichen sclerosus issues/concerns

Sexual function

Are you currently sexually active?
YesNo
Are you in a positive and trusting relationship?
YesNo
Is sex less enjoyable?
YesNo
Do you have sexual function issues-low desire, less interest?
YesNo
Are you having trouble reaching an orgasm?
YesNo
Was there a point where sexual enjoyment was better?
YesNo
Do you have pain with sex?
YesNo
Is this issue causing stress in your relationship?
YesNo

Incontinence - Bladder Leaking

Have you tried anything to help?
YesNo
How long have you had an issue of leaking?
YesNo
Do you have leaking with sneezing, laughing, or coughing?
YesNo
Do you have leaking with running, jumping, exercising?
YesNo
Do you wear pads to protect yourself from having an accident?
YesNo
Do you limit your water intake due to leaking?
YesNo
Do you wake in the night to go to the bathroom?
YesNo
Have you tried anything to help with this issue?
YesNo
If yes, please describe what your concerns are.

Hormones

Are you having regular periods?
YesNo
Do you feel your hormones may be out of balance?
YesNo
How you been though menopause?
YesNo
Have you had a Pap smear in the past year?
YesNo
If yes, are you on Hormone Replacement?
YesNo
If you have been through menopause, and are not on Hormone Replacement, have you had your Hormone levels tested?
YesNo
Do you have vaginal dryness?
YesNo

Please fill out if you have Lichen Sclerosus

Do you have lichen sclerosus
YesNo
Have you had any surgical procedures for lichen sclerosus?
YesNo
What treatments have you tried in the past?
What are your goals with O shot for Lichen?

Confirmation

Do you affirm that you have answered all questions truthfully and to the best of your knowledge?
Yes

Dr. Kelley and her staff customize a program for you to feel and look vibrant at any age.

Our practice focuses on Regenerative medicine and Regenerative Aesthetics.

Pricing
Lean Body Program
Exilis Skin Tightening
Microneedling stimulates Collagen and Elastin
Sculptra
PRP Injections
PRP Hair Therapy
O Shot

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