June 15, 2023 admin No Comments Medical History Step 1 of 5 0% CLIENT INFORMATION & MEDICAL HISTORYIn order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidentialPERSONAL HISTORYClient Name(Required) First Last Today's Date(Required) DD slash MM slash YYYY Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)OccupationHome Address(Required)City(Required)State(Required)Zip Code(Required)Home Phone(Required)Work PhoneEmergency 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 HISTORYAre 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 MEDICATIONSWhat 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) HISTORYHave 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
