Intake copy

Client Name ___________________________________________ Today’s Date ___________________ Home Address _______________________________________________________________________ City ________________________ State ______ Zip ____________ Birth Date ____________________ Best daytime phone (______) ___________________ Alternate Phone (______) ___________________ Would you like to receive special discount offers via email? ___ Yes ___ No Name:_______________________________________________________________________ Emergency Contact Name and Number ___________________________________________________ How did you hear about us? ____________________________________________________________ Which of the following best describes your skin type? (please circle one type) VII. Brown, moderately pigmented skinVIII. Black skin How often do you use tanning salons or sun bathe? __ Once a week __ Once a month __Seldom/never MEDICAL HISTORY
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 any 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 PLEASE CONTINUE ON BACK OF PAGE
Do you have any of the following conditions? (please check all that apply) ___ Cancer ___ Diabetes ___ High blood pressure ___ Herpes ___ Arthritis ___Frequent cold sores ___ HIV/AIDS ___ Hepatitis ___ Keloid scarring ___ Skin disease/Skin lesions ___ Seizure disorder ___ Hormone imbalance ___ Thyroid imbalance ___ Blood clotting abnormalities ___ Any active infection Please explain _______________________________________________________________________ ___________________________________________________________________________________ Are you presently or have you used any of the following: ___ Retinoic acid ___ Glycolic/Salicylic acid ___ Hydroquinone ___ Accutane ___ Zovirax Are you pregnant or lactating? ___ Yes ___ No Are you on hormone therapy? ___ Yes ___ No Are you on birth control pills? ___ Yes ___ No History of sun allergies? ___ Yes ___ No Have you ever had a skin allergy to a cosmetic or skin care product? ___ Yes ___ No if yes, from what?______________________________________________________________________ Do you have brown spots? ___ Yes ___ No if yes, how long have you had them?_______________ Do you have a history of acne or periodic breakouts? ___ Yes ___ No if yes, check all that apply: ___ Pimples ___ Whiteheads ___ Blackheads ___ Cysts ___ Pustules ___ Other Are you on any medication to control acne? ___ Yes ___ No if yes, what kind? _____________________________________________________________________ Does your skin ever flake or feel tight and dry? ___ Frequently ___ Occasionally ___ Very rarelyHow soon after you cleanse do you see a shine on your face? ___ 15 -30 min ___ 1 -3 hours ___ 4+ Recently had any Botox, Laser, resurfacing or cosmetic surgery? ___ Yes ___ No Explain:_______ ___________________________________________________________________________________Does your skin heal quickly? ___ Yes ___ No Do you ever get cold sores? ___ Yes ___ No Do you form thick scarring (Keloid) from a cut or burn? ___ Yes ___ No Do you use wax or depilatories? ___ Yes ___ No Do you have any other health problems or medical conditions we should know about? Please list:__________________________________________________________________________ Have you ever had an allergic reaction to any of the following? (Please check all that apply) ___ Food ___ Latex ___ Aspirin ___ Lidocaine ___ Hydrocortisone or skin bleaching agentsExplain reaction: ______________________________________________________________________ What condition do you wish to improve with your visit today? ___________________________________ ____________________________________________________________________________________ MEDICATIONS
Have you ever used Accutane? ___ Yes ___ No if yes, when did you last use it? ________________
What oral medications are you presently taking? ___ Birth control ___ Hormones ___ Others Please list: __________________________________________________________________________ Are you on any mood altering or anti-depression medication? ___ Yes ___ No if yes, what type? _____________________________________________________________________ What topical medications or creams are you currently using? ___ RetinA __ Others if yes, please list: _____________________________________________________________________ What herbal supplements do you use regularly? _____________________________________________
Have you had any recent tannin or sun exposure that changed the color of your skin?
Have you recently used any self-tanning lotions or treatments? ___ Yes ___ No
Have you ever had laser hair removal? ___ Yes ___ No Have you used any of the following hair removal methods in the past six weeks? ___ Waxing ___ Electrolysis ___ Plucking ___ Tweezing ___ Stringing ___ Depilatories Did you form thick or raised scars from the cuts or burns? ___ Yes ___ No Do you get hyper-pigmentation (darkening of the skin) or hypo-pigmentation (lightening of the skin) or marks after physical trauma? ___ Yes ___ No Please describe:___________________________________________________________________________________________________________________ For our female clients:
Are you trying to become pregnant? ___ Yes ___ No Are you breast feeding? ___ Yes ___ No Are you using contraception? ___ Yes ___ No ____________________________________________________________________________________ ACKNOWLEDGEMENT:
I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor, or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. Client Signature ______________________________________________ Date: ______/______/201___ Medical Director ______________________________________________ Date: ______/______/201___ Reviewed treatment procedure and approved to proceed


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