Client Health History: Radio Frequency/High Frequency Treatment of Skin Irregularities Health History Intake

Client Health History: Radio Frequency/High Frequency Treatment of Skin Irregularities Health History Intake

Client health history intake for radio frequency and high frequency skin treatments. Please complete all applicable fields and review the acknowledgment before signing.
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Eligibility and Skin Profile
Are you over the age of 18 years?
Skin Type (Fitzpatrick Scale)
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?
How would you describe your skin?

Other
When were you last exposed to the sun?
Treatment History and Cosmetic Products
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?
If yes, when?
What body area(s) were treated?
Describe your experience
Have you used Accutane in the past year?
Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmentation?
Please list topical/oral products
Injectables or implants received

Other
If Other injectables or implants, please specify
If yes, when?
What body area(s)?
Medical History and Current Conditions
Do you have hyperpigmentation or hypopigmentation or marks after physical trauma?
If yes, please describe
Do you form thick or raised scars from cuts or burns?
Have you had chemotherapy in the past 6 months?
Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Please indicate if you have any of the following conditions

Other
Do you have a history of Erythema Ab Igne (EAI)?
Do you have any other health condition not mentioned here?
If yes, please list other health conditions
Have you consumed drugs or alcohol in the last 24 hours?
Have you undergone any recent surgery?
If yes, please explain
Please list all vitamins and supplements including herbal remedies you take regularly
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly
Is there anything else you would like us to know?
Acknowledgment and Signatures
Certification / Acknowledgment
Client Name (Printed)
Client Signature
Client Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Esthetician/Technician Name
Esthetician/Technician Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Health History: Radio Frequency/High Frequency Treatment of Skin Irregularities Health History Intake

Client Information

Eligibility and Skin Profile

Treatment History and Cosmetic Products

Medical History and Current Conditions

Acknowledgment and Signatures