Medical & Skin History
Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name
*
First
Last
E-mail
*
We will never SPAM or sell email addresses to third parties.
Phone:
ex. 555-555-5555
Birthdate:
ex. 01/05/1960
What is the best way to contact you?
*
Phone call
Email
Text
All
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Are you allergic to anything?
*
NO
YES
If yes, please list allergies:
Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?
*
NO
YES
If yes, please list reason:
Have you had skin cancer?
*
NO
YES
If yes, please list area(s):
Do you have any permanent cosmetics or tattoos on the areas being treated?
*
NO
YES
Have you had any of these health conditions in the past or present?
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart problem
Varicose veins
Arthritis
Asthma
Eczema
Epilepsy
Fever blisters
Hepatitis
Herpes
Cold sores
Immune disorders
HIV/AIDS
Lupus
Metal implants
Phlebitis
Blood clots
Insomnia
Seizure disorder
Keloid scarring
Migranes
Skin disease
Active Infection
Sensitive to Bright Lights (LED Light)
Do you follow a regular exercise program?
*
NO
YES
After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 24 hours.
Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.
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Do you smoke or vape?
*
NO
YES
Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment.
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
Do you currently use any of the following?
Retin-A
Renova
Adapalene
Differin
Glycolic Acid
AHA
Retinol
Accutane
Tazorac
Scrubs or Peels
At home laser
I understand that I must discontinue use of ALL of the above 5 days prior to treatment and for 1 week after treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.
*
YES, I will discontinue.
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?
*
NO
YES
If yes, please explain:
Do you use bleaching creams or Hydroquinone daily?
*
NO
YES
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Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
*
NO
Hyper-pigment
Hypo-pigment
Have you used an acne medication?
*
NO
YES
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past?
*
NO
YES
Please explain the details:
Have you ever had an ALLERGIC reaction to any of the following?
AHA's
Retinoid
Cosmetics
Medicine
Food
Animals / Insects
Sunscreens
Iodine
Pollen
Fragrance
Shellfish
Latex
Topical RX
Nuts
Asprin
Baking Soda
Essential Oils
Honey
Laundry Detergent/Bleach Etc
NONE
Female Clients
Are you pregnant or trying to become pregnant?
NO
YES
Do you have Mirena IUD, Copper IUD or other implanted birth control?
NO
YES
Are you taking oral birth control?
NO
YES
Brand name of birth control:
Are you lactating?
NO
YES
Any current menopause problems?
NO
YES
If yes, please explain:
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Skin Care History
When washing my face:
*
I use hot water
I use warm water
I use cool or cold water
How often do you use a skin regimen?
*
1x per day
2x per day
I do not use a regimen
Do you have an aversion to hot or cold tempuratures used on your face?
*
YES
NO
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Preparing for your appointment
Please bring all of the products you currently use to your appointment, or fill them in below. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will also be suggested Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin. You will have the opportunity to receive 30% off your first purchase of products.
Current skin care products you use at home. Include brand names and product names. You can upload below a photo of all your products in a single photo.
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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 esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Carin McGrath of Skin By Carin McGrath from liability and assume full responsibility thereof.
*
To cancel an appointment please contact 818.301.9096 or booking@skinbycarin.com at least 24 hours prior to your appointment. Cancellations not made within 24 hours will be charged a no-show fee.
*
I understand the cancellation policy. YES or NO
OPTIONAL: I grant permission to Skin By Carin McGrath to use photos of my progress for marketing purposes on www.skinbycarinmcgrath.com or other business listing pages such as Instagram.
YES or NO
Date
*
-
Month
-
Day
Year
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Signature or ( Parent Signature for Minors)
*
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