Medical History for MOXI/BBL and ForeverBare

Medical History for MOXI/BBL & ForeverBare Skin Procedures
Choice Health & Wellness Tamera Nolan ARNP

415 W. Third Ave Moses Lake, WA 98837
Name
Address
Phone #1
Phone #2
Type a question

FemaleMale
Age
Referred by
Reason for consultation

AcneBrown Spots or Sun DamageEnlarged Blood VesselsFine Lines or WrinklesFlushing of the skinSkin LaxitySkin texture or scarsUnwanted Hair
Questions about skin:
1. How long have you been concerned about this area(s)?
2. At what age did you notice this concern(s)?
Are your present skin concerns getting more pronounced?

YesNo
Have you ever been treated for this concern(s)

YesNo
If yes, when?
What method?
Are you currently taking medication for your skins concern(s)?

YesNo
If yes, what is it?
6. What topical skin medications or products are you currently taking?

Retin-AHydroquinone or bleaching agentNoneOther
Have you ever had laser/IPL Hair Removal?

YesNo
Have you ever used the following hair removal methods in the past 6 weeks?

ShavingWaxingElectrolysisPlucking/TweezingStinging/ThreadingDepilatories
Have you ever had skin resurfacing or rejuvenation or chemical peels

YesNo
Have you ever had treatments for pigmented lesions?

YesNo
Do you form thick or raised scars (keloids) from cuts or burns?

YesNo
Do you experience hyperpigmentation (redness) from burns, cuts, insect bites?

YesNo
Have you ever had cold sores?

YesNo
When were you last exposed to the sun or tanning booth?
Do you use self-tanners

YesNo
Are you planning on vacationing in the sun?

YesNo
Personal History:
Do you smoke?

YesNo
If yes, how many packs per day?
What is your daily consumption of alcohol?
Do you wear contact lenses?

YesNo
Medical History
Are you currently under the care of a physician?

YesNo
If so, for what:
Do you have any of the following?

ArthritisAny active infectionBleeding disordersBruisingDark spots of pregnancyDiabetesEpilepsy or seizuresHeart diseaseHepatitisHerpes simplexHigh blood pressureHormone imbalanceHIV/AIDSMRSASensitive TeethSkin Cancer or molesSkin injuryVision Deficits
Do you have allergies to any of the following (check all that apply)

MedicationsLatexFoodAnesthesia
Do you take any of the following?

AccutaneAntibioticsAnti-coagulantsAnti-depressantsAppetite depressantsAspirin or IbuprofenCortisone or steroidsHormone/contraceptivesInsulinSedativesThyroid medication
Are you taking herbal preparations or vitamins? (St. John's Wort, Vitamin E)
For female patients:
Are you pregnant or planning to be pregnant?

YesNo
I have answered the questions contained in this questionaire to the best of my knowledge. I understand that it is ,u responsibility to inform my practitioner of my current health conditions while seeking treatment as a patient. I will update this information as it occurs.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical History for MOXI/BBL & ForeverBare Skin Procedures

Questions about skin:

Personal History:

Medical History

For female patients: