ENVY SKIN CLINIC CLIENT ASSESSMENT

ENVY SKIN CLINIC CLIENT ASSESSMENT
Name
Address
City
State
Zip
Daytime Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
DaytimeCell
Email
example@example.com
YesNo
Date of Birth

MonthDayYear
Date
Age
Marital Status
Occupation
Employer
How did you hear about us?
FinancingCredit CardCheckCash
ACNEFACIAL REDNESSSAGGING SKINEXCESSIVE SWEATINGUNEVEN SKIN TONEDRY SKIN/OILY SKINLARGE PORESSUN DAMAGEUNWANTED HAIRMELASMAFAT/CELLULITELEG VEINSSCARRINGFACIAL VEINSSTRETCH MARKSWRINKLES
Other
What do you currently use for skin care?
YESNO
YESNO
YESNO
BOTOXFILLER INJECTIONSLIPOSUCTIONVEIN TREATMENTSHAIR REMOVALSKIN TIGHTENINGACNE TREATMENTSCHEMICAL PEELS
ENVY SKIN CLINIC CLIENT ASSESSMENT
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Name of Pharmacy:
Pharmacy Phone Number / Location
Format: (000) 000-0000.
YESNO
Please list past and current medical concerns/problems:
Please list surgeries you have had:
ENVY SKIN CLINIC CLIENT ASSESSMENT
Violet, GreenAmber, Light BlueBlueHazel, GrayBrown
Sandy Red.Blond.Chestnut, Dark Blond.Brown.Black.
Very PalePale with a Red TintOliveTan .Dark Brown.
Many.Several.FewIncidental.None
Painful redness, blistering, peeling.Blistering followed by peeling.Burns, sometimes followed by peeling.Rarely burns.Never had burns.
Hardly or not at all.Lightly tan.Reasonably tan.Tan very Easily.Turn dark brown quickly.
Very sensitive.SensitiveNormal.Very resistant.Never had a problem.
More than 3 months ago.2-3 months ago.1-2 months ago.Less than 1 month ago.Less than 2 weeks ago.
Never.Hardly ever.Sometimes.Often.Always.
Are you currently or have you ever suffered from any of these medical complications:
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
YESNO
COMMENTS
ENVY SKIN CLINIC CLIENT ASSESSMENT
Please list Medications you are taking (including supplements, herbal preparations, and Over the counter medications)
YESNO
YESNO
Please list any drug allergies
*I verify that all information given is accurate to the best of my knowledge:
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