GLYMED

Client should complete the following, as directed, as thoroughly and in as much detail as possible.

Name

Date

Street Address

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

City

Format: (000) 000-0000.

State

Zip

Email

example@example.com

Birthdate

Date

Emergency Contact

Relation to Contact

Your Physician

Occupation

Format: (000) 000-0000.

How did you hear about us?

Occupation

Please indicate which services you are interested in:

What do you wish to change about your skin?

Medical History Are you currently, or have you previously experienced any of the following:

Type

If you are currently experiencing or being treated for any health-related condition, please describe:

you are currently experiencing or being treated for any health related condition, please describe

Have you ever had surgical or non surgical procedure? If yes, where on your body was the surgery performed?

Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side effect

Please list all over the counter and prescription medications you are currently taking

Please indicate if you have ever used any of the following medications for skin treatment:

Accutane Cortisone Staticin Benzoyl Peroxide

Fosdex Glycolic Acid Salicylic Acid Lactic Acid

Renova Clindamycin Tazoratene Metrogel

What condition were you treating with this medication(s)?

When was the last time you used these medications?

Are you pregnant? Yes No Are you planning a pregnancy in the near future? Yes No

Are you currently on any type of hormone therapy? If yes please describe

Do you have regular periods? Yes No Are you going through menopause? Yes Do you have any hormone imbalance? Yes No NoWhen? Have you undergone surgical menopause (hysterectomy) Yes

No

When?

What skin care products are you currently using?

Are you wearing a daily sunscreen?

Type

SPF

Have you ever treated or been treated for a skin condition? If yes, what condition?

How did you treat the condition:

AestheticianSelf treated with products purchased from:

Were you happy with the result?

Yes

Are you currently treating or being treated for any skin condition?

Do you come in contact with any chemicals at work?

Do you work around excessive heat or cold?

Do you use Personal Protective Equipment (PPE* ")? If so, what type and for how long? "Masks, gloves, shields, etc.

How often do you exercise?

What is your stress level?

How many minutes a day are you exposed to sunlight?

How many hours a week do you use a tanning bed?

Do you get cold sores?

What is your ancestory? Father

Please indicate any of the following that apply to your eating habits: Fast food Salt your food Baked BreadSeafood

Dairy products Ethnic or Spicy foods

How much water do you drink per day?

Caffeine?

Carbonated drinks?

Do you smoke tobacco products? Have you changed your brand of skin care products in the last year? If yes, why did you change?

Do you smoke tobacco products?

Average alcohol consumption per week?

Have you changed your brand of skin care products in the last year? If yes, why did you change?

T understand and agree that I am ultimately responsible for payment in full for services received.

Signature of Patient or Responsible Party

Date

Relationship to Patient

GLYMED

GAIN

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