MEDICAL HISTORY FORM 2/2021

Medical History Form

CONFIDENT IMAGE CHEZ FRANCE
Date

MonthDayYear
Name

First NameLast Name
Contact Email
example@example.com
Cell #
Please enter a valid phone number.
Alternate Phone or Landline #
Please enter a valid phone number.
General Health
Do you see your physician on a regular basis?

YesNo
Date of last physician appt:

MonthDayYear
Are you currently under the care of a dermatologist?

YesNoIf yes, please note reason here:
Do you have a history of persistent skin rash produced by prolonged or repeated sun exposure?

YesNo
Do you have a history of skin cancer?

YesNoIf yes, please list type here:
Date skin cancer was last treated:

MonthDayYear
Any cancer lesion(s) removed in the area to be treated?

YesNoPlease list where lesion was previously :
Do you have any of the following conditions?

Active infectionArthritisBlood ClottingCold SoresDermatitisDiabetesEczemaEpilepsy/SeizureHeart DiseaseHepatitisHerpesHigh Blood PressureHIV /AIDSHormone ImbalanceHypertensionKeloid ScarringMetallic ImplantMolesPace MakerPsoriasisRosaceaMetalic ImplantSkin Disease/Skin Lesions:Vitiligo / LupusTattoosThyroid ImbalanceWarts
Do you have any other medical conditions not listed above?

YesNoPlease list here:
Are you pregnant or trying to become pregnant?

YesNo
Are you breastfeeding?

YesNo
Do you smoke?

YesNo
Do you consume 2 or more glasses of alcohol per day?

YesNo
Have you ever had an allergic reaction to any of the following?

Aloe VeraAspirinFoodHoneyHydrocortisoneHydroquinoneLatex / BandaidsLidocaineMetalSkin Brightening ProducsDescribe the reaction you experienced:
Medication
What oral medication(s) are you presently taking?

AnalgesicsAnticoagulantsAnti-depressantsAnti-epilepticsAnti-inflammatoryAntibioticsAspirinBirth Control PillsHigh Blood Pressure PillsHormone TherapyInsulinMood Altering SupplementsTestosterone BlockersPlease list any other oral medication and/or supplements:
Have you ever used Accutane?

YesNoIf yes, how long since your last application:
What topical medications or creams are you currently using?

Retinol prescribed by physicianRetin-A / Vitamin ARetinoidsTazoracTretinoin CreamVitamin CPlease list any other topical medicated creams:
Treatment History
Have you used any of the following hair removal methods in the past six weeks?

Depilatory CreamElectrolysisLaserShavingSugaringThreadingTweezingWaxing
Do you work outdoors or spend a lot of time in the sun?

YesNo
Do you use self tanning products or tanning beds?

YesNo
Have you ever had a severe sunburn or trauma to the area you wish to treat?

YesNo
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or dark spots / melasma?

YesNo
Have you ever experienced keloid scarring, thick or raised scars post a surgical cut, superficial cut or burn?

YesNoPlease describe:
If treating the facial area, please upload a photo of your lovely face (Front)
Please upload a photo of your lovely face (Left Side)
Please upload a photo of your lovely face (Right Side)

The following are a series of questions designed to determine your Fitzpatrick Score. Please select 1 answer in each section that best describes you and how your skin responds without sunscreen or protection?*

	(0) LIGHT OR BLUE	(1) BLUE OR GREEN	(2) HAZEL OR LIGHT BROWN	(3) DARK BROWN	(4) BROWNISH BLACK
Select Eye Colour

	(0) RED, STRAWBERRY BLONDE	(1) BLONDE	(2) DARK BLONDE, CHESTNUT BROWN	(3) DARK BROWN	(4) BLACK
Select Natural Hair Colour

	(0) REDDISH	(1) VERY PALE	(2) PALE WITH BEIGE TINT	(3) LIGHT BROWN	(4) DARK BROWN
Select Skin Colour

	(0) MANY	(1) SEVERAL	(2) FEW	(3) ODD 1 OR 2	(4) NONE
Do you have freckles on sun exposed areas?

	(0) PAIN, REDNESS, BLISTERING, PEELING	(1) BLISTERING FOLLOWED BY PEELING	(2) BURNS SOMETIMES FOLLOWED BY PEELING	(3) RARELY BURNS	(4) NEVER HAD BURNS
When in the sun too long my skin experiences...

	(0) HARDLY ANY OR NOT AT ALL	(1) LIGHT TAN	(2) REASONABLE TAN	(3) TAN VERY EASILY	(4) TURN DARK BROWN QUICKLY
How brown do you get?

	(0) NEVER	(1) RARELY	(2) SOMETIMES	(3) OFTEN	(4) ALWAYS
Do you turn brown several hours after tanning?

	(0) VERY SENSITIVE	(1) SENSITIVE	(2) NORMAL	(3) CAN HANDLE SUN	(4) NEVER HAD A PROBLEM
What happens to your face when in the sun?

	(0) MORE THAN 3 MONTHS AGO	(1) 2-3 MONTHS AGO	(2) 1-2 MONTHS AGO	(3) LESS THAN 1 MONTH AGO	(4) LESS THAN 2 WEEKS AGO
When was the last time you tanned including tanning beds and self tanning lotions?

	(0) NEVER	(1) HARDLY EVER	(2) SOMETIMES	(3) OFTEN	(4) ALWAYS
How often is the area to be treated exposed to sun?

What is your ethnic background; mother, father or grandparents...?
Terms & Conditions: Ultimately, we are here to help you and want your experience to be a pleasant one. We thrive on providing a safe and effective treatment and wish to assist in any way possible; it is your responsibility over the duration of your treatments to tell us if there has been a change in medication, prescriptions; topical or otherwise, or a change in your health and if you have had others skin care treatments outside our office or a change in home skincare regime and/or product used. Skin reactions can occur though rare, and are avoidable if you follow our standard protocols and recommendations. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

I confirm that I am not pregnant at this time, and that I have not applied topical Retinol A, Tazorac, Steroid creams or other prescription Retinoids within the last week, nor have I taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator. I understand that how I take care of my skin after treatment influences my risk of complications. I agree to follow the clinics recommendations. I agree to stay out of the sun or tanning beds and to use sufficient sun block for 2 - 4 weeks following my treatment. I agree to call the clinic if I develop any markings on my skin after treatment, and I will not pick at them.

I certify that the preceding medical, personal and skin history statements are true and correct.
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Medical History Form

General Health

Medication

Treatment History