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Contact Info
2552 Stonebrook Pkwy suite # 730, Frisco.Texas 75034
469 803 5833
[email protected]
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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
(Required)
First
Last
Today's Date
(Required)
DD slash MM slash YYYY
Date of Birth
(Required)
Month
1
2
3
4
5
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12
Day
1
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31
Year
2025
2024
2023
2022
2021
2020
2019
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2016
2015
2014
2013
2012
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
(Required)
Occupation
Home Address
(Required)
City
(Required)
State
(Required)
Zip Code
(Required)
Home Phone
(Required)
Work Phone
Emergency Contact Phone
(Required)
How were you referred to us?
Which of the following best describes your skin type?
(Required)
Always burns, never tans
Always burns, sometimes tans
Sometimes burns, always tans
Rarely burns, always tans
Brown, moderately pigmented skin
Black skin
Do you regularly use tanning salons or sun bathe?
(Required)
How often?
(Required)
MEDICAL HISTORY
Are you currently under the care of a physician?
(Required)
Yes
No
If yes, for what:?
(Required)
Are you currently under the care of a dermatologist?
(Required)
Yes
No
If yes, for what: ?
(Required)
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?
(Required)
Yes
No
Do you have any of the following medical conditions? (Please check all that apply)
(Required)
N/A
Cancer
Diabetes
Herpes
High blood pressure
Arthritis
Frequent cold sores
HIV/AIDS
Keloid scarring
Skin disease/Skin lesions
Seizure Disorder
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Do you have any other health problems or medical conditions? Please list:
(Required)
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
(Required)
Food
Latex
Aspirin
Hydrocortisone
Hydroquinone or Skin Bleaching Agents
Other
MEDICATIONS
What oral medications are you presently taking?
(Required)
Birth Control Pills
Hormones
Other
Are you on any mood altering or anti-depression medication?
(Required)
Have you ever used Accutane?
(Required)
Yes
No
If yes, when did you last use it?
(Required)
What topical medications or creams are you currently using?[
(Required)
Retin-A®
Other
What herbal supplements do you use regularly?
(Required)
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?
(Required)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin?
(Required)
Yes
No
Have you recently used any self-tanning lotions or treatments?
(Required)
Yes
No
Do you form thick or raised scars from cuts or burns?
(Required)
Yes
No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
(Required)
Yes
No
If yes, please describe:
(Required)
For Our Female Clients:
Are you pregnant or trying to become pregnant?
(Required)
Yes
No
Are you breastfeeding?
(Required)
Yes
No
Are you using contraception?
(Required)
Yes
No
Consent
(Required)
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.
Client’s Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
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