Download Fillable Preventative Medical History Form (PDF) Step 1 of 4 25% Today's Date MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY Age Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhoneEmail SexFemaleMaleEmergency Contact Phone NumberHow did you hear about us? Occupation Packages purchased are non-refundable, but are transferable to another procedure or product within the clinic. Your Concerns? Sun Damage Redness Scars Acne Excess fat or cellulite Sagging skin Veins Skin Lesions Wrinkles Skin texture Latisse Unwanted hair Preventative Medicine/Hormones Hair Restoration Stem Cells PRP Female/Male Rejuvenation Breast Lift Melasma Permanent cosmetics/tattoo Eyebrows Eyeliner Areola Lightening Other: Describe Skin Type AllergiesCheck if you have ever had an allergic reaction to any of the following and describe what happened below. NONE Drugs Foods (including eggs & milk) Others (including environmental) Specify (Drugs) Specify (Foods) Specify (Other allergies) ReactionList all medications, including supplements:SkinCheck or fill up all of the following that apply.History of skin cancer or pre-malignant moles: where/whenAny keloid or hypertrophic scars - Location:Electrolysis, waxing, or laser hair removal Electrolysis, waxing, or laser hair removal Use of sunlamp/tanning bed/suntan outdoors Use of sunlamp/tanning bed/suntan outdoors Ever had a chemical peel? Yes No Type Glycolic Laser TCA Phenol Jessner Salicylic Other Previous electrolysis, waxing, or laser hair reduction? When and where?Previous laser vein reduction? Yes No Schlerotherapy (injection) Schlerotherapy (injection) Other active skin disorders? Describe:Psoriasis, ecOther active skin disorders? Psoriasis, eczema, rashes, vitiligo, herpes simplex , acne, or other.Forehead/Eyes/EyebrowsCheck all of the following that apply.Eye disorders Contact lenses Dry eyes Eye makeup sensitivities Scar Glaucoma Lasik /eye surgery Ptosis (eyelid droop) Uneven Brows Alopecia Pull out lashes/eyebrow compulsively (Trichotillomania) Other Other eye disorders: General MedicalCheck or fill up all of the following that apply.General Medical disorder Diabetes Heart Palpitations, pacemaker or defibrillator High blood pressure Mitral valve prolapse or valve implants Thyroid abnormalities Polycystic Ovarian Syndrome (PCOS) Taken Accutane within the last 6 month Metal or implants in area to be treated History of Cancer History of Botulism immunization/military Cold sores/fever blisters/herpes Recent use of anti-malaria medications Asthma Seizures Birth control or hormone replacement Smoke? How long? Currently on blood thinners or anticoagulants such as Coumadin, aspirin, ibuprofen, alcohol, Vit. E, bruise easy or clotting disorder? Autoimmune or neuromuscular disorders - describe: Do you have a condition such as Hepatitis, HIV or undergoing treatment such as chemotherapy that could affect healing? Use of medications or herbs known to induce photosensitivity to light or use Retinal, Renova, Differin, Hydroquinone Fade cream: Current use of controlled substances - describe: Please list any surgeries:If you are currently under a physician’s care for any condition, describe:Physician’s Name City PhoneI have carefully reviewed this history and find it to be correct to the best of my knowledge. I have carefully reviewed this history and find it to be correct to the best of my knowledge. SignatureDate MM slash DD slash YYYY Skin Type Worksheet* THIS INFORMATION IS REQUIRED FOR SKIN ANALYSIS *Your Ethnicity: AnalysisWhat is the color of your eyes?What is the natural color of your hair?What is the color of your skin in unexposed areas?Do you have freckles on sun-exposed areas?What happens when you stay in the sun for too long?To what degree do you turn brown?Do you turn brown several hours after sun exposure?How does your face respond to the sun?When did you last expose yourself to the sun, tanning bed, or tanning cream?Do you expose the area to be treated to the sun?Total Raffle BasketContentsValueQuantity 1) White: SkinBetterInstant Effect Eye GelAlphaRet Overnight CreamAlto Defense SerumToneSmart SPF 68 Compact$437.50 1 2) Pink: epionce Sensitive SkinMilky Lotion CleanserBalancing TonerLite Lytic TreatmentRenewal Facial CreamIntensive Nourishing CreamTravel Mug$386.861 3) Red: OrthomolecularMitocore MultivitaminsOrthobiotic ProbioticCollagen PowderCollagen Factors$237.391 4) Orange1 Syringe of Restylane Family Filler$6256 5) Yellow: epionce Normal SkinGentle Foaming CleanserBalancing TonerLytic TreatmentRenewal Facial LotionIntense Defense SerumTravel Mug$419.291 6) Green1 Syringe Radiesse Filler$6254 7) Blue: epionce Oily/Acne SkinLytic Gel CleanserPurifying TonerLytic Plus TreatmentRenewal Lite Facial LotionRenewal Eye CreamTravel Mug$347.951 8) Purple: jane iredale makeupPomMist Hydration SpraySmooth Affair PrimerHydropure Lip GlossHandi BrushCompact PP Foundation$2381 9) Rainbow50 Units of Botox150 Units of Dysport$650$75064 10) Pastel: Skin ResurfacingScarlet Laser MicroneedlingSecret RF Face and NeckEclipse Microneedling Face and NeckExo Kit$700$700$415$2004321 11) Silver: Hair Restoration1 Derive1 Viviscal1 Aquafirme Hair$6001 12) Black1 Syringe Juvederm Filler$6756 EmailThis field is for validation purposes and should be left unchanged. 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