Medical Questionnaire

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

E-mail

example@example.com

Phone Number

Area CodePhone Number

Date of Birth

MonthDayYear

Emergency Contact

Emergency Contact Number

Have you been under the care of a physician, dermatologist or other medical professional within the past year please answer yes or no, if yes explain?

Any recent surgery, including plastic surgery? please answer yes or no, if yes explain?

Any skin cancer? please answer yes or no, if yes explain?

Have you had any of these health conditions in the past or present?(Please check all that apply and provide additional information in the space provided)

Have you had any allergies past or present? Please check all that apply

(Provide additional information in the space provided)

Do you follow a restricted diet?

Do you follow a regular exercise program?

List ALL medications you take regularly:

Have you used any of these products above in the last 3 months?

Have you ever had any of the adverse reactions below after using any skin care products in the past current?

Have you used an acne medication? If Yes, when? and Which drug?

Do you form thick or raised scars from cuts or burns?

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

Do you wear contact lenses?

Have you been exposed to the sun or used a tanning bed in the last 48 hours?

Do you have any metal implants or wear a pacemaker?

Do you suffer from sinus problems?

Are you taking oral contraceptives?

Are you pregnant or trying to become pregnant?

Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

Please provide details

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the aesthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. PLEASE ENTER YOUR NAME BELOW.

Date

Your Health