Client Medical History Form
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
*
Emergency Contact
*
Emergency Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Medical history conditions
Diabetes
Heart disease
High blood pressure
Autoimmune disorder
Thyroid disorder
Cancer
Epilepsy or seizures
Hepatitis
HIV/AIDS
Blood clotting disorder
Anemia
Keloid scarring
Psoriasis
Eczema
Rosacea
Cold sores (HSV-1)
Skin cancer
Vitiligo
Active skin infection
Recent illness or fever
If yes, please explain
Medications and Allergies
Medications
*
Blood Thinners
Aspirin
Accutane (within 12 months)
Steroids
Retinol/Retin-A/Tretinoin
Antibiotics
Immunosuppressants
Hormone Therapy
Weight-Loss Medications
None
Other Medications
If yes, please list below
Allergies
*
Latex
Lidocaine
Epinephrine
Nickel
Metals
Adhesives
Fragrances
Cosmetic ingredients
Pigments
Antibiotic ointments
None
Other
Skin and Cosmetic History
Skin History
*
Acne
Open wounds
Rashes
Sunburn
Active cold sore
Moles in treatment area
Recent scar
Recent tattoo
Recent cosmetic procedure
None
Skin History - Please explain
Cosmetic Treatment History
*
Botox
Dermal fillers
Laser treatment
IPL
Chemical peel
Microneedling
Facial surgery
Permanent makeup
None
Cosmetic Treatment History - Treatment dates/notes
Pregnancy and Lifestyle
Pregnancy
*
Pregnant
Trying to become pregnant
Breastfeeding
None of the above
Lifestyle
*
Consumed alcohol (last 24–48 hours)
Used recreational drugs (last 24–48 hours)
Used caffeine excessively (last 24–48 hours)
Tanned (last 24–48 hours)
Had significant sun exposure (last 24–48 hours)
Exercised heavily (last 24–48 hours)
Not Applicable
Treatment Contraindications and PMU
Treatment Contraindications
*
Accutane in the last 12 months
Retinol within the last 5–7 days
Prescription exfoliants
Recent waxing
Recent facial surgery
Radiation treatments
None
Previously had PMU?
Please Select
Yes
No
Color corrections needed?
Please Select
Yes
No
Ever had an allergic reaction to tattoo ink?
Please Select
Yes
No
History of cold sores (Lip Blush Clients)?
Please Select
Yes
No
Permanent Makeup - Area treated
Permanent Makeup - Year
Signatures
Client Signature
*
Client Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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