CACI Non-Surgical Face & Body
Health Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date
*
-
Month
-
Day
Year
Date
Do you have any allergies?
*
Type Yes/No and then list all allergies as necessary.
Do you have a pacemaker?
*
Are you pregnant or breast feeding?
*
Have you had, or do you have any forms of cancer?
*
If yes, please give details.
Do you suffer from epilepsy?
*
If yes, are you on medication to control it?
Do you have any heart conditions?
*
If yes, please provide details.
Do you suffer with Diabetes?
*
If yes, please provide details.
Have you had any recent infections or inflammation?
*
If yes, please provide details.
Do you have Multiple Sclerosis?
*
Yes/No
Do you have any prosthesis/silicone implants?
*
Yes/No
Do you have any varicose veins?
*
Yes/No
Do you have any moles?
*
Yes/No
Have you recently had Botox/Dermal fillers?
*
If yes, please provide details.
Do you suffer with high/low blood pressure?
*
If yes, please provide details and any medications.
Do you have any skin disorders?
*
Please provide details.
Have you had any recent operations?
*
If yes, please provide details.
Do you suffer with an over-active thyroid?
*
Yes/No
Do you use Retina A/Roaccutane?
*
If yes, please state when you last used it.
Do you have any skin lesions, cuts, abrasions?
*
If yes, please provide details?
Do you have any metal implants? (inc IUD)
*
If yes, please provide details?
Are you on anti-depressants?
*
Of yes, are you on Prozac?
Do you suffer with thrombosis/phlebitis?
*
Yes/No
Do you have any tumours?
*
Yes/No
Do you suffer with headaches/migraines?
*
Yes/No
Do you have any severe muscle disorders?
*
Yes/No
Do you have highly sensitive/delicate skin?
*
Yes/No
Do you suffer with severe active acne?
*
Yes/No
Do you suffer with asthma/breathing difficulties?
*
If yes, please provide details.
Do you have any semi-permanent makeup?
*
Yes/No
Are you currently under any medical supervision?
*
Please provide details,
Please provide your doctors name, address and contact number.
*
Please write the full address and phone number.
What is your regular skin care routine?
*
Please list.
What are your target areas of concern?
*
Please list.
What are your treatment expectations?
*
Please list.
Please sign your name below.
*
Submit
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