CACI Non-Surgical Face & Body

CACI Non-Surgical Face & Body

Health Questionnaire
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date*

MonthDayYear
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.*

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