Medical History Form
Name
*
First Name
Last Name
Mobile No.
*
Please enter a valid phone number.
Format: 00000000000.
Ok to Text?
*
Please Select
Yes
NO
Email
*
example@example.com
Date Of Birth 00/00/00
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor Practice
*
Emergency Contact
First Name
Last Name
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Which body area(s) or conditions would you like treated? Please mark N/A if no.
*
Please answer each of the following questions:
Do you have ANY allergies to medications, foods, latex, or other substances? Please list:
Do you Smoke?
*
Please Select
Yes
No
Do you have ANY current or chronic medical conditions?Disclose any history of heat urticaria, impaired sensation, impaired circulation diabetes, cardiac disease, autoimmune disorder or any immunosuppression, blood disorders, cancer, bacterial or viral infections, hypersensitivity to cold, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness.
*
Please Select
Yes
No
If Yes, Please list, Please mark N/A if no..
*
Do you have ANY current or chronic skin conditions?Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition.
*
Please Select
Yes
No
If Yes, Please list, Please mark N/A if no..
*
Are you under a doctor’s care?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no..
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Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no..
*
Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no..
*
Are you taking oral steroids (eg. prednisone, dexamethasone)? *
*
Please Select
Yes
No
Do you have a pacemaker or external defibrillator? *
*
Please Select
Yes
No
Do you have any metal implants under the area being treated? *
*
Please Select
Yes
No
Do you have a history of light-induced seizures?
*
Please Select
Yes
No
Do you have a history of Herpes in the area being treated? *
*
Please Select
Yes
No
Do you have any open sores or lesions? *
*
Please Select
Yes
No
Have you had radiation therapy in the area being treated? *
*
Please Select
Yes
No
Do you have a history of keloid scaring or hypertrophic scar formation? *
*
Please Select
Yes
No
In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?
*
Please Select
Yes
No
List Product, Date Used: Please mark N/A if no. *
In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no.
*
Have you had any cosmetic procedures in the past 6 months?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no.
*
Have you had any permanent make-up, tattoos, implants, or fillers, including: but not limited to collagen, autologous fat, Restylane, ect.?
*
Please Select
Yes
No
If yes, please list locations and dates, Please mark N/A if no.
*
In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?
*
Please Select
Yes
No
If yes, please list locations and dates, Please mark N/A if no.
*
Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?
*
Please Select
Yes
No
Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?
*
Please Select
Yes
No
For Women Only
Are you pregnant or breastfeeding?
Please Select
Yes
No
N/A
Are your menstrual periods regular
Please Select
Yes
No
N/A
Have you been diagnosed with Polycystic Ovarian Disorder?
Please Select
Yes
No
N/A
Signature
*
Submit
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