Client Name
Today’s Date
Date of Birth
Age
Occupation
Home Address
City
State
Zip Code
Home Phone
Work Phone
Emergency Contact Name and Phone
How were you referred to us?

Which of the following best describes your skin type? (Please Write the following Option )

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?

Are you currently under the care of a physician?YesNo

If yes, for what:?

Are you currently under the care of a dermatologist?YesNo

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? YesNo

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

CancerDiabetesHerpesHigh blood pressureArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHepatitisHormone imbalanceThyroid imbalanceBlood clotting abnormalities

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)FoodLatexAspirinLidocaineHydrocortisoneHydroquinone or skin bleaching agentsOthers

What oral medications are you presently taking?[checkbox* medications "Birth control pills" "Hormones" "Others" (Please list): ]

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

Have you ever used Accutane? YesNo

If yes, when did you last use it?

What topical medications or creams are you currently using?[checkbox* creams "Retin-A®" "Others" (Please list):]

What herbal supplements do you use regularly?

Have you ever had laser hair removal? YesNo

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

Have you had any recent tanning or sun exposure that changed the color of your skin?YesNo

Have you recently used any self-tanning lotions or treatments? YesNo

Do you form thick or raised scars from cuts or burns?YesNo

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?YesNo
If yes, please describe:

For our female clients:

Are you pregnant or trying to become pregnant? YesNo Are you breastfeeding? YesNo
Are you using contraception? YesNo