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 INFORMATION

Client Name                                                         Today’s Date                        

Date of Birth                    _____Age                

Home Address___________________________________________________________________

City______________________ State_______Zip Code                        

Home Phone (             )                ________Email Address:                                 _______

Emergency Contact Name and Phone                                                                

How were you referred to us?                                                                         

MEDICAL HISTORY

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: __________________________

__________________________________________________________________________________

Hospitalizations/operations: _______________________________________________________

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: ______________