Client Information

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Contact Info

682-715-2538

revisedbodyandwellness@gmail.com

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Client Information & Medical History

In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.

Personal History

First Name

Last Name

Today's Date

Occupation

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Emergency Contact

Phone

How Were You Referred To Us?

Are You Currently Under the Care Of a Physician?

If Yes, For What?

Are You Currently Under the Care Of a Dermatologist?

If Yes, For What?

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?

Do You Have Any of the Following Medical Conditions? (Please Check All That Apply)

Cancer

Diabetes

Epilepsy/Seizures

Pacemaker

Arthritis

High Blood Pressure

Blood Clotting Abnormalities

Frequent Cold Sores

Herpes

HIV/AIDS

Hepatitis

Thyroid Imbalance

Hormone Imbalance

PCOS

Keloid Scarring

Eczema/Psoriasis

Other (Including Any Active Infections)

Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe your experience)

Food

Latex

Aspirin

Lidocaine

Hydrocortisone

Hydroquinone or skin bleaching agents

Others:

What oral medications are you presently taking?

Birth control pills

Hormones

Others (Please list):

Supplements?

Have you ever used Accutane?

If yes, when did you last use it?

What topical medications or creams have you used in the last 2 weeks or are you currently using?

Retin-A

Others (Please list):

Any tattoos or permanent makeup? (Explain where)

Have you ever had laser hair removal

Have you ever used any of the following hair removal methods in the past six weeks for area(s) to be treated?

Shaving

Waxing

Tweezing

Threading

Depilatories

Electrolysis

Have you had any recent tanning or sun exposure that changed the color of your skin?

Have you recently used any self-tanning lotions or treatments?

Do you form thick or raised scars from cuts or burns?

Do you have hyperpigmentation (darkening of the skin), hypopigmentation (lightening of the skin), or marks after physical trauma?

If yes, please describe:

Any surgeries in the last six months?

FEMALE CLIENTS: Are you pregnant or trying to become pregnant?

FEMALE CLIENTS: Are you breastfeeding?

FEMALE CLIENTS: Are you using contraception?

FEMALE CLIENTS: Regular periods?

FEMALE CLIENTS: Post Menopause?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. I understand Providers do not offer refunds, Instead offers spa credits towards services. Signed:

Dated:

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