In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Client Name Today’s Date
Date of BirthAgeOccupation 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)
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:
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?
Have you ever had laser hair removal? Yes No
Have you used any of the following hair removal methods in the past six weeks?
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.