fcldspa.com - Spa Skin Care History

THE FLORIDA CENTER FOR LASER DENTISTRY MEDICAL SKINCARE HISTORY
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DOB:

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Emergency Contact:
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Please Check if you have any of the Following Health Conditions:

AIDS/HIVHEART PROBLEMSLUPUSCANCERHEPATITISSTROKESDIABETESHIGH/LOW BLOOD PRESSURE THYROID IMBALANCESKIN DISEASE/SKIN LESIONSHORMONE IMBALANCEANY ACTIVE INFECTION
PLEASE LIST ANY OTHER HEALTH CONDITIONS NOT LISTED ABOVE:
PLEASE LIST ANY MEDICATIONS YOU ARE TAKING OR SUPPLEMENTS:
PLEASE LIST ANYTHING YOU ARE ALLERGIC TO:
ARE YOU CURRENTLY PREGNANT:

YESNO
ARE YOU CURRENTLY TRYING TO GET PREGNANT:

YESNO
HAVE YOU EVER USED ACCUTANE:

YESNO
IF YES, WHEN DID YOU LAST USE IT:
DO YOU USE RETIN-A OR TENTINOIN PRODUCTS:

YESNO
HOW OFTEN PER WEEK:
DO YOU USE ANY OTHER TOPICAL PRESCRIPTION CREAM FOR YOUR SKIN:

YESNO
IF YES, PLEASE LIST THE NAME OF THE TOPICAL PRESCRIPTION:
DO YOU CURRENTLY TAKE BIRTH CONTROL OR ANY HOMONE MEDICATIONS:

YESNO
DO YOU SUFFER FROM COLD SORES:

YESNO
DO YOU SMOKE:

YESNO
HOW OFTEN:
DO YOU FORM THICK OR RAISED SCARS FROM BURNS OR CUTS:

YESNO
DO YOU HAVE HYPERPIGMENTATION (DARKENING OF SKIN) OR HYPOPIGMENTATION (LIGHTENING OF SKIN) OR MARKS AFTER PHYSICAL TRAUMA?

YESNO
PLEASE DESCRIBE:
PLEASE CHECK WHICH SKIN TYPE BEST DESCRIBES YOU:

ALWAYS BURNS, NEVER TANSALWAYS BURNS, SOMETIMES TANSSOMETIMES BURN, ALWAYS TANSRARELY BURNS, ALWAYS TANSBROWN, MODERELY, PIGMENTED SKINBLACK SKIN
DO YOU REGULARLY USE TANNING SALONS OR SUN BATHE?

YESNO
DO YOU USE SUNSCREEN DAILY:

YESNO
ARE YOU INTERESTED IN MEDICAL GRADE SKIN CARE PRODUCTS:

YESNO
PLEASE DESCRIBE WHEN YOU LOOK IN A MIRROR WHAT YOU WOULD LIKE TO CHANGE ABOUT YOUR SKIN:
I CERTIFY THAT THE PRECEDING MEDICAL, PERSONAL AND SKIN HISTORY STATEMENTS ARE TRUE AND CORRECT. I AM AWARE THAT IT IS MY RESPONSIBILTY TO INFORM THE ESTHETICIAN OR DOCTOR OF MY CURRENT MEDICAL OR HEALTH CONDITIONS AND UPDATE THIS HISTORY. A CURRENT HISTORY IS ESSENTIAL FOR THE CAREGIVER TO EXECUTE APPROPRIATE TREATMENT PROCEDURES:
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THE FLORIDA CENTER FOR LASER DENTISTRY MEDICAL SKINCARE HISTORY