Permanent Makeup Health Questionnaire
Kendra Neal Studio
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
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Confirmation Email
example@example.com
Occupation
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How did you hear about us?
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Do any of the following apply to you?
Please expand on any question answered 'yes' in the right most column.
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Yes
No
Description
Are you currently pregnant and/or breastfeeding?
Do you have, or have you a positive test for any of the following?
Auto-immune disorder
Thyroid disorder
Hepatitis A, B or C
HIV/AIDS
Jaundice
If yes, please list any that apply in the column to the right:
Have you previously had a permanent makeup (PMU) procedure from a non-KNS artist in the area you are planning to receive PMU? If yes, please describe when/where in the column to the right.
History of allergies, anapyhlactic reactions, or sensitivities to pigments, dyes, disinfectants, metals, latex, hair dye, lidocaine, paints, crayons, glycerin, cosmetics, or soaps? Any other known allergies? If yes, list in the column to the right.
Have you received chemotherapy treatment within the past 6 months? If yes, enter date of final treatment in the column to the right.
Have you had Botox injection in the last 15 days? If yes, where were the injections (answer in the column to the right)?
Are you currently on Accutane, or have you taken it within the last year?
Do you use Retin-A, Glycolic Acid, Vitamin C or other exfoliants? If yes, list in the column to the right.
Have you had a chemical peel? If yes, list date of last treatment in the column to the right.
Do you tint your brows and/or lashes, or currently use eyelash enhancing products? If yes, please list products in the column to the right.
Do you have collagen, Restalyine, Juvaderm, or fat transfers in any part of your face? If yes, please describe in the column to the right.
Do you have a history of herpes infection (cold sores/fever blisters)?
Have you had a herpes (cold sore/fever blister) infection within the last 21 days?
Do you bruise or swell easily?
Do you suffer from a medical skin condition such as keloids, hypertrophic scarring, psoriasis, or any current open wounds or lesions? If yes, please describe in the column to the right.
History of skin disease, skin cancer, or skin lesions at the site of the service? If yes, please describe where/when these occurred in the column to the right.
Do you have a heart condition? If yes, is the condition being monitored or treated by a physician? Please answer in the column to the right.
Are you currently on steroids or anti-inflammatory medications? If yes, please list in the column to the right.
Do you have diabetes or other conditions which may affect blood circulation and/or ability to fight infection? If yes, please describe in the column to the right.
Do you have a history of hemophilia, excessive bleeding, or other blood/bleeding disorder?
Do you have tattoos? If yes, did you heal normally after the procedure? Please describe in the column to the right.
Do you spend a lot of time in the sun and/or a chlorinated pool? List any that apply in the column to the right.
Are you planning any cosmetic surgery in the near future? If yes, when and what type of procedure? Please answer in the column to the right.
Have you had or plan to have laser treatment? Please describe where (on the body)/when in the column to the right.
Have you consumed more than 8oz of alcohol within the past 24 hours?
Do you use sunscreen regularly?
Do you have a history of epilepsy, seizures, fainting or narcolepsy?
Currently using drugs or other treatments with anticoagulants or other medications that thin the blood and/or interfere with blood clotting (blood thinners)?
History of eye disease, glaucoma, disorder, or suffer from frequent eye infections?
Are you currently under a physician’s care for any condition? If yes, please describe in the column to the right.
Have you taken any medications in the past 6 months? If yes, please list in the column to the right.
Do you have other health considerations that could complicate this procedure or your healing? If yes, please describe in the column to the right.
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I hereby certify that all statements contained within the document have been read, answered accurately, and are true to the best of knowledge.
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