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					  CLIENT ID#                    OFF ICE U SE O N LY                              LASER1ST LLC
                                                                    HEALTH HIS TOR Y QUES TIONNA IR E


                              A LL QUESTIONS CONTAINED IN TH IS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME PART OF YOUR CLIENT RECORD.
Name   (Last, First, M.I.):                                                                      M        F           DOB:
              Street                                       City               State    Zip                                Home                   Work          Cell/mobile
Address:                                                                                                    Phone

Email:                                                                                                                  Preferred contact:
Source of Referral:               TV       Radio      Coupons      Newspaper      Signal      Friend   Yellow pages       Other     internet
Primary reason                       Hair Removal               Rosacea          Wrinkles                     Microderm                 Other /describe nature of visit?
for initial visit:                   Vein Removal               Acne             Dark Spots                   Cellulite

                                                                  PERSONAL MEDICAL/HEALTH HISTORY

Please check yes                                                                                                    Check one (when exposed to the sun for 1
                                 Y     N                                    Y     N    Skin Type            Tan                                                                Y
or no:                                                                                                              hour):
Allergies                                   Exercise                                   Caucasian                    Always Burns, never tans                               1
Heart Condition                             Smoke                                      Hispanic                     Usually burns.tans less than average                   2
Diabetes                                    Microdermabrasion                          Mediterranean                Sometimes mild Burn, tans about average                3
Rosacea                                     Chemical Peels                             African American             Rarely burns,tans more than average                    4
Cold Sore/ Herpes                           Laser Resurfacing                          American Indian              Rarely burns,tans profusely                            5
Acne                                        Broken capillary concerns                  Asian                        Never burns,deeply pigmented                           6
Sarcoid                                     Wrinkle Concerns                           Other:
Pregnant/Lactating                          Sun damage concerns
Tatoos/Perm.Makeup                          Pigmentation concerns
Lupus
                                           Acne                                                                           Skin Background
                                                                             Y    N                                                                                    Y       N
Do you experience Cystic break outs?                                           Are you currently sunburned?
Do you have any scarring as a result of acne?                                  Do you use tanning beds?
Do you have a history of break outs?                                           Are you using a chemical tanning solution?
If so, what is the Frequency of your break outs?                               Do you use sunscreen on regular bases?
    Frequent        Occasional    Rarely                                       Prolonged sun exposure (tanning bed) in the past two weeks?
Have you been on Accutane in the past 6 months?
Have you waxed, used depilatories, bleaches or other chemical processes?
Have you had Botox or Collagen injections the past 6 months? If yes and less than 3 months, approximate dates? Dates:
Do you use any topical ointments?       Retin-A     Glycolic     Lactic Acid      Hydroquinone      Other
What type of skin care products are you using?
How much water do you consume daily?
Do you have any allergies?
List all medications you are currently taking(blood thinners, antibiotics, herbs, supplements, vitamins,asprin,etc):



Describe the nature of your visit?




What are your expectations?




Check Other Services of interest:                  Pigmented lesions or brown spot removal                                   Other: List below
  Laser vein removal                               Laser Hair removal (list different areas) in box below
  Non- Ablative LaserFACIAL



I certify that the above medical history information is accurate and correct:



Client Signature:____________________________________________________                                  Date:________________________


DR/Tech Signature:___________________________________________________                                  Date:________________________

				
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posted:4/17/2011
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