Client Information & Medical History

By Paul Woods,2014-05-15 17:56
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Client Information & Medical History

    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

    Client Name________________________ Today’s Date________

    Date of Birth________ Age ___ Occupation __________________

    Home Address__________________________________________

    City ____________________State_______ Zip Code___________

    Home Phone_(___)___________ Work Phone_(___)____________

    Emergency Contact Name and Phone________________________

    How were you referred to us?______________________________

    Which of the following best describes your skin type? ( please circle one)

    1. Always burns, never tans

    2. Always burns, sometimes tans

    3. Sometimes burns, always tans

    4. Rarely burns, always tans

    5. Brown, moderately pigmented skin

    6. Black skin

    Medical History

    Are you currently under the care of a physician? __Yes __No

    If Yes, for what:__________________________________________


    Are you currently under the care of a dermatologist? __Yes __No

    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? __Yes __No

    Parker Laser and Anti-Aging Clinic/ Parker Day Spa

    Do you have any of the following medical conditions? Please check all that apply __Cancer __Diabetes __ High blood pressure __Herpes __Arthritis

    __Frequent cold sores __HIV/AIDS __Keloid scarring __Skin Disease/lesions __Seizure disorder __Hepatitis __ Hormone imbalance __ Thyroid imbalance __Blood clotting abnormalities __ Any active infection

    __ Any other health problems or medical conditions? Please List:____ _________________________________________________________

    E-Mail Address (for our use only)


    Have you ever had an allergic reaction to any of the following? Please check all that apply

    __Food __Latex __Lidocaine __Hydrocortisone

    __Hydroquinone or skin bleaching agents __Other Please



    What oral medications are you presently taking? __ Birth control pills __Hormones __Other Please list: ____________________________________________________ Are you on any mood altering or anti-depression medication?___________________ Have you ever used Accutane? __Yes __No

    If yes, when did you last use it?___________________________________________ What topical medications or creams are you currently using? __RetinA __Other Please list:__________________________________________________________________ What herbal supplements do you use regularly?_______________________________

    Parker Laser and Anti-Aging Clinic/ Parker Day Spa


    Have you ever had laser hair removal? __Yes __ No

    Have you used any of the following hair removal methods in the past six weeks? __Shaving __Waxing __Electrolysis __Plucking __Tweezing __Stringing __Depilatories Have you had any recent tanning or sun exposure that changed the color of your skin? __Yes __No

    Have you recently used any self-tanning lotions or treatments? __Yes __No Do you form thick or raised scars from cuts or burns? __Yes __No

    Do you have Hyper-pigmentation (darkening of the skin) or Hypo-pigmentation or marks after physical trauma? __Yes __No If Yes describe:______________________________ ________________________________________________________________________ For Female Clients Only:

    Are you Pregnant or trying to become pregnant? __Yes __No

    Are you breastfeeding? __Yes __No

    Are you using Contraception? __Yes __No

    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 care giver to execute appropriate treatment procedures.

    Signature________________________________________ Date__________________

My initials acknowledge Parker Day Spa and Parker Laser Clinic’s 48 hour cancellation

    policy. A $35 fee will be accessed for all appointments not given this courtesy. Appointments after 6 p.m (prime appointments) will be accessed a $50 fee. This fee will automatically be put on your credit card. Should we have no credit card on file, you will be accessed this fee at your nets appointment. ________Initials

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