| Full Name | Robert Smith |
| Date of Birth | December 9, 1978 |
| Sex | Male |
| Occupation | Marketing Manager |
| Presenting Complaint | Robert is looking for lip enhancement to balance his facial features. He is seeking a subtle change. |
| Medical History | Allergies: 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 History | Recent dental procedures: Root canal treatment 3 months ago. Ongoing dental problems: None. Cold sores or herpes simplex infections: No history. |
| Cosmetic and Dermatological History | Previous 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. |
| Lifestyle | Diet: 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 Health | Mental health diagnoses: None. Unusual stress or pressure: Going through a divorce, high stress. |
| Current Lip Health | Current lip conditions: No sores, cuts, or infections. |
| Obstetric and Gynecologic History | N/A |
