Patient Information and Medical History

Patient Information and Medical History
Today’s Date:

Month Day Year
Date
Name: *
Date of Birth: *

Month Day Year
Date
Address *

Address

Street Address Line 2

City State

Zip
Occupation: *
Cell No. *

Area Code Phone Number
Home No.

Area Code Phone Number
Work No.

Area Code Phone Number
Referred By
Emergency Contact Name: *
Emergency Contact No. *

Area Code Phone Number
Email *
example@example.com
May we send you monthly emails regarding our specials? *

Yes No
Which of the following best describes your skin type?

Always burns, never tans Always burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Brown, moderately pigmented skin Dark Brown skin
Medical History
Currently under the care of a physician?

Yes No
If yes, for what?
Currently under the care of a dermatologist?

Yes No
If yes, for what?
History of erythema abigne, a persistent skin rash produced by prolong or repeated exposure to moderately intense heat or infrared irritation?

Yes No
Do you have, or have you had a history of any of the following medical conditions? (Please check all that apply)

Cancer Lymph Node Removal Diabetes High Blood Pressure Cardiac Disorder Herpes Arthritis Cold Sores HIV/AIDS Keloid Scarring Skin lesion/disease Seizure Disorder Hepatitis Hormone Imbalance Immune Imbalance Thyroid Imbalance Blood Clotting Abnormalities Any Active Infection
Any other health or medical conditions?
Allergic Reactions: (Please check all that apply)

Food Eggs Milk Latex Aspirin Lidocaine Numbing Cream Epinephrine (EPI) Vaseline Hydrocortisone Hydroquinone or skin bleaching agents Other
Oral medications you are presently taking?
Have you ever used Accutane?

Yes No
Topical medications or creams you are currently using?

Retin A
Herbal supplements used regularly
Do you eat fish regularly?

Yes No
What are your main concerns or changes you wish to address?
History
Have you ever had laser hair removal?

Yes No
Hair removal methods in the past 6 weeks?

Shaving Wax Electro Pluck Tweeze
Have you used tanning bed or sun exposure that changed skin color?

Yes No
Have you used self-tanning lotions or treatments?

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
Female Clients Only
Are you pregnant or trying to become pregnant?

Yes No
Breastfeeding?

Yes No
Birth Control?

Yes No
Hormones?

Yes No
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 tech, 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.
Patient / Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Patient Information and Medical History

Medical History

History

Female Clients Only