Client information & medical history



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CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY

Client Name Today’s Date


Date of Birth Age Occupation
Home Address_______________________ City____________________ State___Zip Code
Home/Mobile Phone ( ) Work Phone (____)
Email Address:_________________________________________________________________
Emergency Contact Name and Phone
How did you hear about us?

Were you referred to us by someone?______

Name of individual so we may thank them:____________________________________
Which of the following best describes your skin type? (Please circle one type number)

I Always burns, never tans

II Always burns, sometimes tans

III Sometimes burns, always tans

IV Rarely burns, always tans

V Brown, moderately pigmented skin

VI Black skin
Do you regularly use tanning salons or sun bathe? How often?

MEDICAL HISTORY

Are you currently under the care of a physician? Yes  No

If yes, for what:

Are you currently under the care of a dermatologist? Yes No

If yes, for what:

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? Yes No

Do you have any of the following medical conditions? (Please check all that apply)

Cancer Diabetes High blood pressure Herpes Arthritis

Frequent cold sores HIV/AIDS Keloid scarring Skin disease/Skin lesions

Seizure disorder Hepatitis Hormone imbalance Thyroid imbalance

Blood clotting abnormalities Any active infection

Do you have any other health problems or medical conditions? Please list: __________________

______________________________________________________________________________

Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced) Food Latex Aspirin Lidocaine Hydrocortisone Hydroquinone or skin bleaching agents Others:

MEDICATIONS


What oral medications are you presently taking? Birth control pills Hormones

Others (Please list):

Are you on any mood altering or anti-depression medication?

Have you ever used Accutane? Yes No, If yes, when did you last use it?

What topical medications or creams are you currently using?  Retin-A® Others (Please list):


What herbal supplements do you use regularly?

HISTORY


Have you ever had laser hair removal? Yes No

Have you used any of the following hair removal methods in the past six weeks?

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories

Have you had any recent tanning or sun exposure that changed the color of your skin? Yes No

Have you recently used any self-tanning lotions or treatments? Yes No

Do you form thick or raised scars from cuts or burns? Yes No

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? Yes No If yes, please describe:

For our female clients:

Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No

Are you using contraception? Yes No

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.


Signature Date:




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