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Advanced Chemical Peel Health History intake
Name
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SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):
Very fair skin; blonde or red hair; light-colored eyes; freckles common
Fair skinned; light hair, light eyes
Very common skin type; fair; eye and hair color var
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Black skin: rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?
Yes
No
Please list the products you use regular : Facial Cleanser, Moisturizer, Toner, Serum , Scrubs, Sunscreen, Retinal, Glycolic Acid, Enzymes, Peptides or Growth Factors
How would you describe your skin? Normal , Combination, Oily , Dry
When were you last exposed to the sun (including tanning beds)?
Do you use sunless tanning products?
Yes
No
if yes, when was it fast applied?
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
Have you had chemical peel treatments in the past?
Yes
No
if yes, when?___________ Describe your experience
Are you currently on birth control? Yes/No
If yes, please describe
Have you consumed drugs or alcohol in the last 24 hours?
Yes
No
Are you currently using, or have you used in the past year, any of the following?
Isotretinoin (Accutane)
Tretinoin (Retinoic Acid)
Acyclovir
Glycolic Acid
Salicylic Acid
Adapalene (Differin)
Hydroquinone
Azelaic Acid
Lactic Acid
Spironolactone
If yes, when?
Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmentation? Please List:
Have you ever had any of the following injectables or implants? Botox , Juvederm , Radiesse , Restylane , Perlane , Silicone Collagen , Sculptra , Dysport , Other
If yes, when?___________ What body area(s)?
Have you had any facial cosmetic surgeries/procedures, piercings, metal implants, tattoos, or use of a pacemaker within the past year?
Yes
No
If yes, when?
Have you had any laser resurfacing treatments in the past six weeks?
Yes
No
If yes, when?
Have you used any of the following hair removal methods in the past six weeks? Shaving , Waxing , Electrolysis,Tweezing ,Threading , Depilatories
Have you had chemotherapy in the past 6 months? YES/NO
Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions? Eczema , Dermatitis , Hormone imbalance , Pregnancy and/or breastfeeding , Autoimmune disease , Herpes Simplex (cold sore) ,Diabetes
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? Indicate Yes or No
Do you have any other health condition(s) not mentioned here? Yes No If yes, please list _____________________________
Are you currently on birth control? Yes No If yes, please describe
Have you consumed drugs or alcohol in the last 24 hours? Yes / No
Please list all vitamins and supplements including herbal remedies you take regularly
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? Yes/No
I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (le: intense erythema, busters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).
I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my-treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense
I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.
I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist, I understand that l will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding The sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.
I understand that results are not guaranteed and for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.
I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist.
I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.
I have read the above information, I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. f certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.
Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:
Is there anything else you would like us to know?
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 esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.
Client Name (Printed)
Client Name (Signature)
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Date
Esthetician Technician
Date
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