Laser Client Information and Medical History

In order to provide you with the most appropriate laser hair removal or skin care treatment, we would
appreciate your time in completing the fol owing questionnaire. Al information is strictly confidential.
Which of the fol owing best describes your skin type? (please circle one skin type number)
Are you currently under the care of a physician? [ ] Yes [ ] No
Are you currently under the care of a dermatologist? [ ] Yes [ ] No
Do you have a history of livido reticularis, an autoimmune disease, in which the blood vessels are
constricted, or narrowed resulting in mottled discoloration on large areas of the leg or arms? Yes [ ]
Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or
repeated exposure moderately intense heat or infrared irradiation? Yes [ ]
Do you have any of the fol owing medical conditions? (Please check al that apply)
[ ] cancer [ ] diabetes [ ] high blood pressure [ ] herpes [ ] arthritis [ ] frequent cold sores
[ ] HIV/AIDS [ ] keloid scarring [ ] skin disease / skin lesions [ ] seizure disorder [ ] hepatitis
[ ] hormone imbalance [ ] thyroid imbalance [ ] blood clotting abnormalities
[ ] any active infection
Do you have any other health problems or medical conditions? Please list:
What oral medications are you presently taking? [ ] ACCUTANE [ ] birth control pil [ ] hormones [ ] others (please list): 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 [ ] Others (please list) Have you ever had laser hair removal? [ ] Yes [ ] No Have you used any of the fol owing 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 hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma? [ ] Yes [ ] No, if yes please describe For our Female clients: Are you pregnant or trying to become pregnant? [ ] Yes [ ] No Are you using contraception? [ ] Yes [ ] No ALLERGIES
Have you ever had an al ergic reaction to any of the fol owing? (please check al that apply and describe the reaction you experienced.) [ ] food [ ] latex [ ] cosmetics [ ] aspirin [ ] lidocaine [ ] hydrocortisone [ ] hydroquinone or skin bleaching agents [ ] others: 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 as a current medical history is essential for the caregiver to execute appropriate treatment procedures.

Source: http://menkesclinic.com/_pdf/Laser-Hair-Removal-Form.pdf

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