CLIENT INFORMATION & MEDICAL HISTORY
In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Client Name Today’s Date
Date of Birth _____Age
City______________________ State_______Zip Code
Home Phone ( ) ________Email Address: _______
Emergency Contact Name and Phone
How were you referred to us?
Which of the following best describes your skin type? (Please circle one type number)
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
Please list any and all medication you are currently taking:_____________________________
Vitamin supplements you are on:__________________________________________________
List any allergies:________________________________________________________________
Are you on any antibiotics at this time? ________________
Are you on any mood altering or anti-depression medication?
Have you ever used Accutane? ❑Yes ❑No, If yes, when did you last use it?
What topical medications or creams are you currently using? ❑ Retin-A® ❑Others (Please list):
Are you currently under the care of a physician? ❑Yes ❑ No
If yes, for what:
Are you currently under the care of a dermatologist? ❑Yes ❑No
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? ❑Yes ❑No
Do you regularly sun bathe or use tanning salons? How often?
Check any of the following illnesses you have or have ever had in the past:
Multiple severe allergies Hypersensitivity to medications Lupus
Cold sores Sensitivity/allergy to lidocaine, sulfa, other: _______________
Autoimmune disease(s) History of allergy to beef, sutures, other: __________________
Myesthenia Gravis Hepatitis Eye disease Numbness
Muscle weakness Multiple Sclerosis Amyotrophic Lateral Sclerosis (ALS)
Parkinson’s Disease Neurological Disorders Lambert-Eaton Syndrome
List and/or explain other medical conditions not listed above: __________________________
WOMEN: Are you pregnant, trying to get pregnant, or lactating (nursing)? _________________
Have you had plastic surgery or other surgery to your face/neck areas and when? ___________
Had Botox injections before? ________ Last treatment? __________ What areas? ___________
Happy with the previous Botox treatments? Explain: __________________
Ever had eyelid/eyebrow drooping after Botox? Explain: ____________________
Do you show a lot of upper eye lid when eyes are open? _____________________
Do your eyelids feel extra heavy or droop when you don’t get enough sleep? __________
Have you had any Dermal Filler procedures before? ______ If yes, what, and were you
satisfied with the results? _____________________________________________________
Have you ever had laser hair removal? ❑Yes ❑No
Have you used any of the following hair removal methods in the past six weeks?
❑Shaving ❑Waxing ❑Electrolysis ❑Plucking ❑Tweezing ❑Stringing ❑Depilatories
Have you had any recent tanning, sun exposure, or self tanner that changed the color of your skin? ❑Yes ❑No
Do you form thick or raised scars from cuts or burns? ❑Yes ❑No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? ❑Yes ❑No If yes, please describe:
I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understood the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.
Client Signature: _______________________________________________Date: ______________