Lash History Form

Lash History Form
Name*

First NameLast Name
Have you ever had eyelash extensions before*

YesNo
Have you ever had eyelash extensions removed?*

Yes, please explain why in the next questionNo
Please explain why you had eyelash extensions removed:
Have your used under eye gel patches before*

YesNo
Have you had permanent cosmetics applied to your eyes?*

Yes, (Please explain below)No
If you selected yes to the question above, Please explain any frequency, dates and any adverse reactions below
Do you wear glasses /contacts/both?*

GlassesContactsNo, neitherBoth
Do you have a tendency to rub your eyes or pull on your lashes?*

Yes, I frequently rub my eyesYes, I frequently pull on my eyelashesYes to bothNeither
Do you go tanning ( In salon or outside) or get spray tans?*

YesNo
Are you pregnant? If yes, please discuss this proceedure with your doctor.*

YesNo
Which side do you sleep on?*

Right sideLeft sideBackStomach
Do you exercise?*

YesNoOther
Are you on a special diet?*

YesNo
Do you have an allergy to any of the following : ( please check all that apply)*

Acrylates or Cyanoacrylates ( Dermabond)Nail AdhesiveTape ( bandages/latex)Long lasting or waterproof cosmeticsCosmetics, Skincare products, topical creams, or other topical products or ingredientsOther
If you selected " Other" above, please explain below:
Have you experienced any of the following:*

Eye surgery, words or infectionsExfoliation, skin tightening, or skin resurfacing facial treatment ( example: acne treatment, chemical peels, microdermabrasion , or laser treatments)Retin-A, Accutane or similar productsHistroy of eye disease, condition, injury, or surgery that affected your hair/natural eyelashes growth or loss?Other
How would you describe your hair growth cycle?*

SlowAverageFastUnsure
Please note that some medications used to treat the following conditions may cause hair/ natural eyelash loss. If you are on medications to treat any of the following , please check mark them below: ( Although, these are not medical conditions, birth control and hormone therapy may result in the thinning or loss of natural lashes)

AcneThyroid diseaseBirth ControlFungusUlcersHigh CholesterolGlaucomaAnticoagluantsGoutCancerDepressionConvulsions/EpilepsyParkinson's diseaseDiet/Weight LossDry eye syndromeHigh Blood PressureAutoimmune DiseasesHormone Imbalance, Hormone TherapyInflammationAllergies ( When treated with non-steroidal anti-inflammatory drugs)None of the aboveOther
Please indicate any current medications , herbal supplements and Vitamins you are taking:
Please mark all conditions that apply:

AlopeciaAsthmaBack PainBlepharitisBronchitis ( Chronic)Conjunctivitis ( Pink eye)Cold solresClaustrophobiaDisbetesStrokeMigranesOcular RosaceaOveractive BladderRosaceaSeizure DisorderSensitive EyesSensitivity to lightStressThyroid DiseaseDry eye syndromeEye sties or soresHeavy eyelidsLeaky eye or excessive tearingHormonal disorders or changesAutoimmune disases ( Chohn's disease, arthritis, lupus, ulcerative colitis, etc)Tendency of redness, rashes, or hivesTrichotillomonia ( hair, or eyelash pulling(None of the aboveOther
Additional comments:
Should be Empty: