Client History Form

Name

Date of Birth

Age

Sex Sex Male Female Other

Home Address

Home Phone #

Work Phone #

Cell Phone #

Email Address

Whom may we thank for referring you to this office?

What are your specific concerns and goals?

What areas do you want treated?

Emergency Contact Name & Number:

Are you currently under a doctor’s care? Are you currently under a doctor’s care? Yes No

Doctor’s name

Have you ever seen a dermatologist for your skin? Have you ever seen a dermatologist for your skin? Yes No

Dermatologist name

What medications are you currently taking?

Are you currently on any mood-altering or depression medication? Are you currently on any mood-altering or depression medication? Yes No

Do you have any allergies? If yes, describe

Are you Diabetic? Are you Diabetic? Yes No

Are you Pregnant? Are you Pregnant? Yes No

HIV/Aids? HIV/Aids? Yes No

Hepatitis A/B/C? Hepatitis A/B/C? Yes No

Heart Problems? Heart Problems? Yes No

History of herpes simplex or cold sores? History of herpes simplex or cold sores? Yes No

Are you presently or have you used any of the following: Are you presently or have you used any of the following: Retin-A AHA/BHA Hydroquinone Accutane Blood Thinners Zorax

When did you last take medication?

What strength?

How Long?

Are you on hormone therapy? Are you on hormone therapy? Yes No

If Yes, How Long on HRT?

Are you on birth control pills? Are you on birth control pills? Yes No

If Yes, How Long on Birth Control?

Besides shaving, have you used any of the following hair removal methods in the past six weeks? Besides shaving, have you used any of the following hair removal methods in the past six weeks? Waxing Electrolysis Tweezing Delilatories

What date was your last treatment?

What areas were treated?

Were you satisfied with your treatments? Were you satisfied with your treatments? Yes No

If not satisfied with previous treatments? Please Describe

Have you ever had a chemical peel? Have you ever had a chemical peel? Yes No

Type of Chemical Peel and Date if Yes?

Do you use sunblock/sunscreen daily? Do you use sunblock/sunscreen daily? Yes No SPF 15 SPF 30 SPF 45 SPF 60-65

Are you often in the sun? Are you often in the sun? Yes No

Have you or a member of your family had skin cancer? Have you or a member of your family had skin cancer? Yes No

If Family had skin cancer, please describe

Do you have a history of acne or periodic breakouts? Do you have a history of acne or periodic breakouts? Yes No

Are you currently taking medication for acne? Are you currently taking medication for acne? Yes No

If Taking Acne meds, please describe

Have you ever had an allergic reaction to any of the following? Have you ever had an allergic reaction to any of the following? Latex Aspirin Lavender