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Medical History
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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                

Home Address___________________________________________________________________

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: __________________________


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: ______________