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













    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?

    MEDICAL HISTORY

    Are you currently under the care of a physician?YesNo

    Are you currently under the care of a dermatologist?YesNo

    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

    MEDICATIONS

    What oral medications are you presently taking?

    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?

    What herbal supplements do you use regularly?

    HISTORY

    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

    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.