CLIENT INFORMATION & MEDICAL HISTORY In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential. PERSONAL HISTORY Client Name: ________________________________________________
Occupation: _______________________________________
City: ________________ State: ______ Zip Code: _____________
Home Phone: (____) ____________ Work Phone: (____) _________ Cell Phone: (____) ____________ Email Address: ______________________Emergency Contact Name & Phone: ___________________________ MEDICAL HISTORY Are you currently under the care of a physician or dermatologists?
If yes, for what? ________________________________________________________________________ Do you have any of the following medical conditions? (Please check all that apply) Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
Others: _______________________________________________________
MEDICATIONS What oral medications are you presently taking?
Others (Please list) ___________________________________________________________________________
_____________________________________________________________________________________________ Are you using any of these prescribed products?
Trentinoin (Retin-A, Micro®, Renova, Avita) Adepalene (Differin) Azelaic Acid (Azelex®, Finacea™) Tazarotene (Tazorac®) Isotretinoin (Accutane) Triluma™ Metrogel Any other antibiotics__________________________________________________________________________
What herbal supplements do you use regularly? ______________________________________________________
HISTORY Do you or have you had any of the following in the last 14 days? Do you form thick or raised scars from cuts or burns? Do you have Hyper pigmentation (darkening of the skin) or Hypo pigmentation (lightening of the skin) or marks after physical trauma?
No If yes, please describe: _____________________________
FEMALE CLIENTS ONLY Are you currently having or due for your menstrual period?
Are you pregnant or trying to become pregnant?
SKIN Which of the following best describes your skin type? Please check if you are presently using any of the following? What skin care products are you’re currently using? Face:
Other: ________________________________________________________________________________
How would you describe your skin? Please specify: _________________________________________________________________________________ What skin conditions do you want to improve?
Other ______________________________________________________________________________________
Is there any other necessary information you skin care specialists should know before beginning your treatment? If yes, explain_______________________________________________________________________________________
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. Signature: _________________________________________________
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
Please check if permission is granted to use before and after pictures of the treatments.
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.
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Client
Signature:________________________________________________________Date:____________ I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
What are cold sores? Cold sores are annoying, small, painful blisters on the lips and nearby skin, including in the nose and mouth. They usually appear when you are sick or stressed. They are also called fever blisters. How do they occur? Cold sores are caused by the herpes simplex virus. This virus also causes genital herpes. The fluid in the blisters contains live virus. The virus in th
Vol:12 4:1 Triamcinolone intra sheath injection for diabetic flexor enosynovitis (Trigger finger - TF). TF is caused by a disproportion between the flexor tendon and its surrounding tendon sheath, in which smooth gliding of the flexor tendon within its sheath is restricted. The incidence in the general population is 1-2% while that in diabetics is 10 – 20%. Steroid injections for TF in
