Personal Profile and Health History Name: ___________________________________________ Home Phone:_________________________ Address: _________________________________________ Cell Phone:___________________________ City/State/Zip: ___________________________________________________________________________ Birth Date: ____________________________________________Age:____________Gender: M F Occupation: _____________________________ Email Address: ________________________________ How did you hear about us? ____ Forsyth Woman Magazine ____ Open House ____ Forsyth Family Magazine ____ Google Search ____ Winston-Salem Monthly ____ Yahoo Search ____ Friend (So we can thank them!) ___________________________________________________ ____ Other: ___________________________________________________________________________ What treatments are you interested in?       Hair removal Spider vein treatment (laser or injection) Tattoo Removal Ultherapy Weight management Facial rejuvenation and peels     Age spot /freckle treatments Skin care Botox/ Fillers Other __________________________ Females: Are you pregnant? Yes No Are you planning a pregnancy during the course of your treatment? Yes No Your genetic background affects your skin and its response to the laser. Please specify your ethnic origin:  African American  Hispanic  Native American  Asian  Mediterranean  Other  Caucasian  Middle eastern Medical History: Please list ALL medications including prescription and over the counter drugs, vitamins, supplements: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Are you allergic to any medications? __________________________________________________________________________________________ __________________________________________________________________________________________ Please check any that apply:           Acne Bleeding disorders Burns/ skin grafts Diabetes Endocrine disorders Epidermolysis Bullosa Gold therapy Heart disease Hemorrhoids Herpes          High blood pressure Hirsutism Hormone replacement therapy Implants Kaposi’s sarcoma Keloid scars Lupus Permanent make up Polycystic ovarian disease          Port wine stain Precocious puberty Psoriasis Seizures Shingles Skin cancer Tattoos Thyroid disease Vitiligo Other? __________________________________________________________________________________ Previous Surgeries in the area to be treated? ______________________________________________ If the answer to any of the following questions is yes, please explain in the space below: 1. Are you currently being treated for any medical conditions? Yes 2. Have you used Accutane in the past 12 months? Yes 3. Do you have any skin disease or infections in the area to be treated? Yes 4. Do you have skin allergies? Yes 5. Are you allergic to latex, lidocaine, or any lotions? Yes 6. Are you currently using Retin A or Glycolic acid? Yes 7. Have you had a chemical peel or a facial in the past week? Yes 8. Have you had permanent cosmetic tattooing in the area to be treated? Yes 9. Do you have any implants or metal anywhere? Yes 10. Have you had previous laser or other treatment in the area to be treated? Yes 11. Are there any moles with hair in the area to be treated? Yes 12. Are you using a tanning bed or tanning cream? Yes 13. Have you had sun exposure in the past 4-6 weeks? Yes 14. Are you prone to cold sores? (pretreatment indicated) Yes 15. Are you prone to herpes outbreaks? (pretreatment indicated) Yes 16. What products do you currently use on your skin ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ No No No No No No No No No No No No No No No Who is your family doctor? ______________________________________________________________ I confirm that the answers to the questionnaire are true and correct. The consultant has clarified any question I did not understand. Client Name: _____________________________________ Client Signature: _____________________________________ Date: _____________________________________