Asthetic Medical History Form

First Name

Last Name

Date of Birth

Gender

Male

Female

Address

Address Line

City

State

Zip Code

Mobile Number

Family Doctor

Pharmacy

Emergency Contact Person Name

Phone Number

How did you find out about us?

Which body area(s) or condition would you like treated?

Please answer each of the following questions:

Do you have ANY allergies to medications, foods, latex, orother substances? Please List:

Do you smoke?

Yes

Average per day?

Do you have ANY current or chronic medical conditions? YES / NODisclose any history of heat urticaria, diabetes, autoimmunedisorder or any immunosuppression, blood disorders, cancer,bacterial or viral infections, medical conditions that significantlycompromise the healing response, skin photosensitivitydisorders, or any other condition or illness.

Yes

Please List:

Do you have ANY current or chronic skin conditions? YES / NOAlso disclose any history of vitiligo, eczema, melasma, psoriasis,allergic dermatitis, any diseases affecting collagen includingEhlers-Danlos syndrome, scleroderma, skin cancer, or any otherskin condition.

Yes

Please List:

Are you under a doctor’s care?

Yes

If so, for what?

Do you take ANY medications (prescriptions or non- YES / NOprescriptions) including vitamins and herbal supplementson a regular basis?

Yes

Please List:

Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis?

Yes

Please List:

Are you taking oral steroids (eg. prednisone, dexamethasone)?

Yes

Do you have a pacemaker or external defibrillator?

Yes

Do you have any metal implants under the area being treated?

Yes

Do you have a history of light-induced seizures?

Yes

Do you have a history of Herpes in the area being treated?

Yes

Do you have any open sores or lesions?

Yes

Have you had radiation therapy in the area being treated?

Yes

Do you have a history of keloid scaring or hypertrophic scar formation?

Yes

In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?

Yes

List Product, Date Used:

In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?

Yes

List Product, Date Used:

Have you had any cosmetic procedures in the past 6 months?

Yes

Have you had any permanent make-up, tattoos, implants, or fillers, including but not limited to collagen, autologous fat, Restylane, ect.?If yes, please list locations and dates:

In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?

Yes

If yes, please list:

Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?

Yes

Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?

Yes

For Women Only:

Are you pregnant or breastfeeding?

Yes

Are your menstrual periods regular?

Yes

Have you been diagnosed with Polycystic Ovarian Disorder?

Yes