Client Questionare

NAME:

First NameLast Name
DATE:

MonthDayYear
Date
D.O.B.

MonthDayYear
Date
PHONE:
Format: (000) 000-0000.
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CITY:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
STATE:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ZIP:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL:
example@example.com
ARE YOU PREGNANT OR NURSING?
DO YOU HAVE A TENDENCY TO DEVELOP DARK SPOTS ON THE SKIN FROM WOUNDS OR THE SUN?
ARE YOU ALLERGIC TO LATEX?
DOES YOUR SKIN HYPO-PIGMENT (LOSE PIGMENT)
HAVE YOU HAD ANY LASER REMOVAL OR A CHEMICAL PEEL IN THE LAST 6 MONTHS?
DO YOU TEND TO DEVELOP KELOID OR HYPERTROPHY SCARS?
HAVE YOU HAD ANY ISSUES HEALING WITH PREVIOUS TATTOOS?
DO YOU SCAR EASILY FROM MINOR SKIN INJURIES?
DO YOU ROUTINELY USE ANY EXFOLIATING PRODUCTS?
ARE YOU CURRENTLY UNDERGOING RADIATION OR CHEMOTHERAPY?
DO YOU BRUISE EASILY FOR NO OBVIOUS REASON?
HAVE YOU EVER USED ACCUTANE?
ARE YOU DIABETIC?
DO YOU HAVE SEVERE SKIN SENSITIVITY?
DO YOU BLEED EXCESSIVELY FROM MINOR CUTS (EX; PAPER CUTS)
DO YOU HAVE HEPATITIS?
ARE YOU PRONE TO SEIZURES?
DO YOU WEAR CONTACT LENSES?
DO YOU HAVE A TENDENCY TO FAINT OR BECOME DIZZY?
DO YOU HAVE EYE ALLERGIES?
DO YOU CARRY HERPES?
DO YOU HAVE SEVERELY DRY EYES?
ARE YOU ALLERGIC TO LANOLIN OR PETROLEUM BASED PRODUCTS?
DO YOU HAVE GLAUCOMA OR ANY OTHER EYE DISEASE
DO YOU CONSUME ASPIRIN DAILY?
DO YOU HAVE LIP FILLER?
HAVE YOU HAD BOTOX OR ANY SIMILAR INJECTIONS IN THE PAST TWO WEEKS?
DO YOU HAVE ANY MEDICAL CONDITION THAT REQUIRES YOU TO TAKE ANTIBIOTICS PRIOR TO SURGERY OR DENTAL WORK?
IF YOU HAVE ANSWERED "YES" TO ANY QUESTIONS ABOVE, USE THE "NOTES" SECTION OF THIS FORM TO PROVIDE AN EXPLANATION. IF YOU HAVE ANY HEALTH CONDITIONS THAT WILL AFFECT YOUR HEALING, IT IS YOUR RESPONSIBILITY TO CONSULT A PHYSICIAN BEFORE PROCEEDING.
SIGNATURE:
DATE:

MonthDayYear
Date
NOTES
Should be Empty: