Download Fillable Preventative Medical History Form (PDF) Step 1 of 4 25% Today's Date Date Format: MM slash DD slash YYYY Name First Last Date of Birth Date Format: MM slash DD slash YYYY AgeAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhoneEmail SexFemaleMaleEmergency ContactPhone NumberHow did you hear about us?OccupationPackages purchased are non-refundable, but are transferable to another procedure or product within the clinic. Your Concerns? Sun Damage Redness Scars Acne Excess fat or cellulite Sagging skin Veins Skin Lesions Wrinkles Skin texture Latisse Unwanted hair Preventative Medicine/Hormones Hair Restoration Stem Cells PRP Female/Male Rejuvenation Breast Lift Melasma Permanent cosmetics/tattoo Eyebrows Eyeliner Areola Lightening Other: DescribeSkin TypeAllergiesCheck if you have ever had an allergic reaction to any of the following and describe what happened below. NONE Drugs Foods (including eggs & milk) Others (including environmental) Specify (Drugs)Specify (Foods)Specify (Other allergies)ReactionList all medications, including supplements:SkinCheck or fill up all of the following that apply.History of skin cancer or pre-malignant moles: where/whenAny keloid or hypertrophic scars - Location:Electrolysis, waxing, or laser hair removal Electrolysis, waxing, or laser hair removal Use of sunlamp/tanning bed/suntan outdoors Use of sunlamp/tanning bed/suntan outdoors Ever had a chemical peel? Yes No Type Glycolic Laser TCA Phenol Jessner Salicylic Other Previous electrolysis, waxing, or laser hair reduction? When and where?Previous laser vein reduction? Yes No Schlerotherapy (injection) Schlerotherapy (injection) Other active skin disorders? Describe:Psoriasis, ecOther active skin disorders? Psoriasis, eczema, rashes, vitiligo, herpes simplex , acne, or other.Forehead/Eyes/EyebrowsCheck all of the following that apply.Eye disorders Contact lenses Dry eyes Eye makeup sensitivities Scar Glaucoma Lasik /eye surgery Ptosis (eyelid droop) Uneven Brows Alopecia Pull out lashes/eyebrow compulsively (Trichotillomania) Other Other eye disorders:General MedicalCheck or fill up all of the following that apply.General Medical disorder Diabetes Heart Palpitations, pacemaker or defibrillator High blood pressure Mitral valve prolapse or valve implants Thyroid abnormalities Polycystic Ovarian Syndrome (PCOS) Taken Accutane within the last 6 month Metal or implants in area to be treated History of Cancer History of Botulism immunization/military Cold sores/fever blisters/herpes Recent use of anti-malaria medications Asthma Seizures Birth control or hormone replacement Smoke? How long?Currently on blood thinners or anticoagulants such as Coumadin, aspirin, ibuprofen, alcohol, Vit. E, bruise easy or clotting disorder?Autoimmune or neuromuscular disorders - describe:Do you have a condition such as Hepatitis, HIV or undergoing treatment such as chemotherapy that could affect healing?Use of medications or herbs known to induce photosensitivity to light or use Retinal, Renova, Differin, Hydroquinone Fade cream:Current use of controlled substances - describe: Please list any surgeries:If you are currently under a physician’s care for any condition, describe:Physician’s NameCityPhoneI have carefully reviewed this history and find it to be correct to the best of my knowledge. I have carefully reviewed this history and find it to be correct to the best of my knowledge. SignatureDate Date Format: MM slash DD slash YYYY Skin Type Worksheet* THIS INFORMATION IS REQUIRED FOR SKIN ANALYSIS *Your Ethnicity:AnalysisWhat is the color of your eyes?0Light Blue, Grey, or Green1Blue, Grey, or Green2Blue3Dark Brown4Brownish BlackWhat is the natural color of your hair?0Sandy Red1Blond2Chestnut or Dark Blond3Dark Brown4BlackWhat is the color of your skin in unexposed areas?0Reddish1Very Pale2Pale with Beige Tint3Light Brown4Dark BrownDo you have freckles on sun-exposed areas?0Many1Very Pale2Pale with Beige Tint3Light Brown4Dark BrownWhat happens when you stay in the sun for too long?0Painful redness and blistering followed by peeling1Blistering followed by peeling2Burn, sometimes followed by peeling3Rarely Burn4Never BurnTo what degree do you turn brown?0Hardly or not at all1Light colored tan2Reasonable tan3Tan very easily4Turn dark brown quicklyDo you turn brown several hours after sun exposure?0Never1Seldom2Sometimes3Often4AlwaysHow does your face respond to the sun?0Very sensitive1Sensitive2Normal3Very resistant4Very resistantWhen did you last expose yourself to the sun, tanning bed, or tanning cream?0More than 3 months ago12-3 months ago21-2 months ago3Less than 1 month ago4Less than 2 weeks agoDo you expose the area to be treated to the sun?0Never1Hardly ever2Sometimes3Often4AlwaysTotal ScoreSkin Type 0-7I 8-16II 17-25III 25-30IV Over 30V-VI NameThis field is for validation purposes and should be left unchanged.
