Robert Smith

Patient: Robert Smith

Full NameRobert Smith
Date of BirthDecember 9, 1978
OccupationMarketing Manager
Presenting ComplaintRobert is looking for lip enhancement to balance his facial features. He is seeking a subtle change.
Medical HistoryAllergies: Known allergy to lidocaine. Previous surgeries or hospital admissions: Gallbladder surgery at age 35 with no complications. Chronic illnesses: High blood pressure, controlled with medication (Lisinopril). Autoimmune diseases: None. Current medications: Lisinopril 20 mg once daily. Negative reactions to medications: Developed hives after local anesthesia with lidocaine during a dental procedure. History of bleeding disorders or prolonged healing: No. Lifestyle habits: Non-smoker, regular alcohol use (3-4 times per week), no recreational drugs.
Dental HistoryRecent dental procedures: Root canal treatment 3 months ago. Ongoing dental problems: None. Cold sores or herpes simplex infections: No history.
Cosmetic and Dermatological HistoryPrevious cosmetic procedures: None. Skin reactions to cosmetic products or procedures: No known reactions. Previous lip fillers or facial injectables: None. Facial laser treatments or skin peeling: None.
LifestyleDiet: Omnivorous diet, minimal fruits and vegetables, high in processed foods. Exercise: Rarely exercises. Significant weight fluctuations: Gained 20 lbs over the past year.
Psychological and Emotional HealthMental health diagnoses: None. Unusual stress or pressure: Going through a divorce, high stress.
Current Lip HealthCurrent lip conditions: No sores, cuts, or infections.
Obstetric and Gynecologic HistoryN/A