LED Therapy Health History Form
Please complete this health history form for LED therapy. Provide accurate contact, emergency contact, medication, and health screening information.
Contact Information
Name
*
Address
*
City
*
State
*
Zip
*
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
Contact Preferences and Referral
Preferred Contact Method
*
Home/Cell Phone
Work Phone
Email
Best Time to Contact
Morning
Daytime
Evening
How did you hear of us?
Emergency Contact
Emergency contact name
*
First Name
Last Name
Emergency contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
*
Medical History Overview
Allergies
Current medications, including oral/topical prescriptions, over-the-counter medicines, herbs, vitamins, and supplements
Health Screening Questions
Are you pregnant or nursing?
*
Yes
No
Details - Are you pregnant or nursing?
Adverse reactions - Are you pregnant or nursing?
Do you wear contacts or glasses?
*
Yes
No
Details - Do you wear contacts or glasses?
Adverse reactions - Do you wear contacts or glasses?
Do you have any heart problems?
*
Yes
No
Details - Do you have any heart problems?
Adverse reactions - Do you have any heart problems?
Do you have high/low blood pressure?
*
Yes
No
Details - Do you have high/low blood pressure?
Adverse reactions - Do you have high/low blood pressure?
Do you currently have any open wounds?
*
Yes
No
Details - Do you currently have any open wounds?
Adverse reactions - Do you currently have any open wounds?
Have you ever been diagnosed with epilepsy?
*
Yes
No
Details - Have you ever been diagnosed with epilepsy?
Adverse reactions - Have you ever been diagnosed with epilepsy?
Do you have an autoimmune disorder or connective tissue disease?
*
Yes
No
Details - Do you have an autoimmune disorder or connective tissue disease?
Adverse reactions - Do you have an autoimmune disorder or connective tissue disease?
Have you had any previous facial treatments?
*
Yes
No
Details - Have you had any previous facial treatments?
Adverse reactions - Have you had any previous facial treatments?
Do you use Retin-A®, Accutane® or any other prescribed topical Vitamin A derivative?
*
Yes
No
Details - Do you use Retin-A®, Accutane® or any other prescribed topical Vitamin A derivative?
Adverse reactions - Do you use Retin-A®, Accutane® or any other prescribed topical Vitamin A derivative?
Do you use any medications that cause light sensitivity?
*
Yes
No
Details - Do you use any medications that cause light sensitivity?
Adverse reactions - Do you use any medications that cause light sensitivity?
Additional Health Information
Any other health condition not listed
Is there anything else we should know about?
Submit
Should be Empty: