Laser business forms c.indd

Name: _________________________________________________ Date of Birth: ______________________________________ Address: ___________________________________________________________________________________________________ City ________________________________________________________________ State ________________ Zip: ____________ Email: _________________________________________________ Today’s Date: ______________________________________ Home Phone:____________________________________________ Business Phone:____________________________________ Cell # or Preferred Contact #: _______________________________ Is it important to be discrete?__________________________ How did you hear about us? ____________________________________________________________________________________ Describe the nature of your visit? ________________________________________________________________________________ ___________________________________________________________________________________________________________ What are your expectations?____________________________________________________________________________________ ___________________________________________________________________________________________________________ Please fill out any of the following that may apply:
Have you been on Accutane in the past 6 months?_______________ Include any other medications that make you photo sensitive (antibiotics): _______________________________________________ Have you taken doxycycline, minocin, minocycline, or vibramycin recently? When?_______________________________ ___________________________________________________________________________________________________________ List all medications you are currently taking (blood thinners, herbs, supplements, vitamins, aspirin etc.): _______________________ ___________________________________________________________________________________________________________ Have you ever had allergic reactions to: Food Latex Nickel Aspirin Lidocaine Hydrocortisone Hydroquinone/Bleaching Agents Other______________________________________ Are you currently under the care of a physician? If so, what for? _______________________________________________________ ___________________________________________________________________________________________________________ Any Allergies: _______________________________________________________________________________________________ ___________________________________________________________________________________________________________ Acne:
Do you have a history of breakouts? Yes No
If so, what is the frequency of your breakouts? Frequent Occasional Rarely
Do you experience cystic breakouts? Yes No
Do you have any scarring as a result from your acne? Yes No
Skin Background:
Skin Disease: ______________________________________ Lesions: _____________________________________________ Chronic Rash: ______________________________________ Melanoma: __________________________________________ Surgical Scars: _____________________________________ Psoriasis: ____________________________________________ Hairy Moles:_______________________________________ Are you currently under the care of a dermatologist? If so, for what? ____________________________________________________Have you had prolonged sun exposure (or tanning bed) in the past 3 days? Yes NoIf so, are you currently sunburned? Yes NoDo you use tanning beds? Yes NoAre you using chemical tanning solutions? Yes NoDo you use sunscreen on a regular basis? Yes NoHave you waxed, used depilatories, bleaches or other chemical processes? ________________________________________How much water do you normally consume daily? __________________________________________________________________ Have you had Botox or Collagen injections in the past 6 months? Yes No If yes, and less then 3 months, approximate dates and location. ________________________________________________________Do you use topical ointments? Retin-A Glycolic Lactic Acid Hydroquinone Other: ___________________________What type of skin care products are you using? _____________________________________________________________________ ___________________________________________________________________________________________________________ Check other services of interest:
Laser Hair Removal (list different areas) ________________________________________________________________________ Laser Vein Removal Non-ablative LaserFACIAL Pigmented Lesions or Brown Spot Removal Other: ________________ I certify that the above medical history information is accurate and correct:
Patient Signature: ________________________________________ Date:_____________________________________________ DR/Tech Signature:_______________________________________ Date:_____________________________________________

Source: http://www.lrhrc.com/assets/patient_medical_history.pdf