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					                                  Creative Skin Care
                       Client Information & Medical History


In order to provide you with the most appropriate laser treatment, we need you to complete the
following questionnaire. All information is strictly confidential.

PERSONAL HISTORY

Client Name___________________________________ Today’s Date____________________

Date of Birth_________________ Age________ Occupation____________________________

Home Address_____________________________ City_________ State____ Zip Code______

Home Phone_________________________ Work Phone______________________________

Email Address________________________________________________________________________

Emergency Contact Name and Phone______________________________________________

How were you referred to us? ____________________________________________________

What treatment are you having today?______________________________________________

What is your Ethnic background __________________________________________________

Which of the following best describes your skin type? (Please circle one type number)

I      Always burns, never tans                    IV     Rarely burns, always tans
II     Always Burns, Sometimes tans                V      Brown, moderately pigmented skin
III    Sometimes burns, always tans                VI     Black Skin

Y/N    Do you regularly use tanning salons or sun bathe? If yes last date of tanning _________

Y/N    Are you interested in other treatments in the future?
       If yes what kind of treatments: ______________________________________________

Y/N    Are you using Biore/Snore stripes? (Discontinue 5 days before & after treatment)

Y/N    Are you using Depilatories? (Discontinue for 7days before & after treatment)

Y/N    Have you had any of the following within the last 14 days: Chemical Peel,
       Microdermabrasion, or any procedure with a medical device?

Y/N    Do you have regular injections of collagen, Botox, Restylane or others?

Y/N    Have you recently had facial surgery? Describe: _______________________________
Y/N    Have you recently had laser resurfacing? If so when:____________________________


MEDICAL HISTORY

Y/N    Are currently under the care of a Physician?
       If yes, for what: _________________________________________________________

Y/N    Are you currently under the care of a Dermatologist?
       If yes, for what: _________________________________________________________

Y/N    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?
Y/N    Do you have any of the following medical conditions? (Please circle all that apply)
       Cancer/ Diabetes/ High blood pressure/ Herpes/ Arthritis/ Frequent cold sores
       HIV/AIDS/ Keloid scarring/ Skin disease/Skin lesions/ Seizure disorder/ Hepatitis
       Hormone imbalance/ Thyroid imbalance/ Blood clotting abnormalities/ Any active
       infection

Do you have any other health problems or medical conditions? Please list:_________________
____________________________________________________________________________

Have you ever had an allergic reaction to any of the following? (Please Circle all that apply and
describe the reaction you experienced) Food/ Latex/ Aspirin/ Lidocaine/ Hydrocortisone/
Hydroquinone/ Skin bleaching agents, Other: _______________________________________
____________________________________________________________________________


MEDICATIONS

What oral medications are you presently taking? (Birth Control Pills/ Hormones/
Others):______________________________________________________________________

Y/N    Are you on any mood altering or anti-depression medication? What:________________

Y/N    Have you ever used Accutane? If yes last date taken:___________________________

Y/N    Are you using Tazorac or Avage? If so how long_______________(Discontinue 10 days
       before & after treatment) NOTE: Contact your doctor before discontinuing use of
       prescription.

What topical medications or creams are you currently using? Retin-A, Other (Please list):
____________________________________________________________________________

What Herbal supplements do you use regularly?______________________________________


HISTORY

Y/N    Have you ever had Laser Hair Removal?
Y/N    Have you used any of the following hair removal methods in the past six weeks?
       Shaving/ Waxing/ Electrolysis/ Plucking/ Tweezing/ Stringing/ Depilatories

Y/N    Have you had any recent tanning or sun exposure that changed the color of your skin?

Y/N    Have you recently used any self-tanning lotions or treatments?

Y/N    Do you form thick or raised scars from cuts or burns?

Y/N    Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening
       of the skin) or marks from physical trauma? If yes describe: ______________________
       ______________________________________________________________________

For our female clients:

Y/N    Are you pregnant or trying to become pregnant?
Y/N    Are you breastfeeding?
Y/N    Are you using contraception?




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 update this history. A current medical
history is essential for all caregivers to execute appropriate treatment procedures.


Signature:______________________________________________ Date:________________




WE HAVE A 24 HOUR CANCELATION POLICY



If you are more than 10 minutes late for an appointment, your appointment will be
rescheduled. In addition, you have the option of either forfeiting one of your package visits or
paying a $30 - $50 charge for not keeping your appointment.

				
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