Beauty Culture - Medical History

Beauty Culture

Client Medical History - Microblading
Name
Birthdate
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Emergency Contact Person
Do you or have you had any of the following: (Click Yes or No)
Pregnant now- Breastfeeding*

YesNo
History of MRSA*

yesno
Diabetes*

YesNo
Cancer?*

YesNo
What type and year?
Chemotherapy/ Radiation*

YesNo
Hepatitis A, B, C, or D*

YesNo
Heart Condition*

YesNo
Taking any blood thinners?*

YesNo
Autoimmune Disorder*

YesNo
Alcoholism*

YesNo
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate?*

YesNo
Any other known allergies?*

YesNo
List Allergies
Botox*

YesNo
Last Treatment
Forehead/ Brow Lift*

YesNo
Face lift*

YesNo
Chemical Peel*

YesNo
Last Treatment
Chemical Peel
Brow or Lash Tinting*

YesNo
Oily Skin*

YesNo
Do you use skin care products containing Retin-A, Glycolic Acid, Alpha Hydroxy Acid, or Beta Hydroxy Acid?*

YesNo
Please list:
Accutane or Acne Treatment*

YesNo
Do you use a tanning booth?*

YesNo
Difficulty numbing with dental work?*

YesNo
Are you currently taking any medications or herbal supplements?*

YesNo
Please list all including over the counter drugs/ herbal supplements.
Any diseases or disorders not listed?*

YesNo
Please list:
All of the above information is true to the best of my knowledge:
Signature*

Clear
Date*
Date
Should be Empty: