phoenixcrystaloptical.com - SPA Patients Only

CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate treatment, please complete the following questionnaire. Information provided is confidential.
PERSONAL HISTORY
Today’s Date:

MonthDayYear
Date
Client Name:

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Occupation:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Emergency Contact
Name:
Phone Number:
Please enter a valid phone number.
Relationship:
How were you referred to us?
PROCEDURES THAT INTEREST YOU
Please put a check next to the services that interest you

PhotofacialSkin ResurfacingSkin TighteningIPL/LASER Hair RemovalScar/stretch MarksAcne Treatments
MEDICAL HISTORY
Are you currently under the care of a physician and /or dermatologist?

YesNo
If yes, for what:
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?

YesNo
If yes, please explain:
Do you have any of the following medical conditions? (Please check all that apply)

CancerDiabetesHigh blood pressureHerpesArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHepatitisHormone imbalanceThyroid imbalanceBlood clotting abnormalitiesMultiple SclerosisAny active infectionOther medical conditions/problems?
Other medical conditions/problems? Please list:
Do you have any dental work such as veneers, or dental implants?

YesNo
Do you have any piercings, dermal implants, tattoos?

YesNo
Please list:

Have you ever had an allergic reaction to any of the following? (Please check 'Yes' or 'No' and describe the reaction you experienced)

	No	Yes	If yes, describe the reaction you experienced
Food
Latex
Aspirin
Lidocaine
Hydrocortisone
Hydroquinone or skin bleaching agents
Others:

MEDICATIONS
Have you ever used:

AccutaneRetin-A®
If yes, when did you last use it?
What oral medications are you presently taking? (Please list)
What topical medications or creams are you currently using? (Pleas list)
SKIN HISTORY
Which of the following best describes your skin type? (Please check only one)

Always burns, never tansSometimes burns, always tansAlways burns, sometimes tansRarely burns, always tansBrown, moderately pigmented skinBlack skin
Have you ever had beer hair removal?

YesNo
Have you used any of the following hair removal methods in the past six weeks?

ShavingWaxingElectrolysisPluckingTweezingThreadingDepilatories
Any recent tanning or sun exposure that changed the color of your skin?

YesNo
Have you recently used any self-tanning lotions or treatments?

YesNo
Do you form thick or raised scars from cuts or burns?

YesNo
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

YesNo
If yes, please describe:
Have you recently had any Botox or filler?

YesNo
SIGNATURE
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the Technician, Esthetician, Therapist, Doctor or Nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to give the best care and execute appropriate treatment procedures.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

CLIENT INFORMATION & MEDICAL HISTORY

PERSONAL HISTORY

PROCEDURES THAT INTEREST YOU

MEDICAL HISTORY

MEDICATIONS

SKIN HISTORY

SIGNATURE