Client Health History: Radio Frequency/High Frequency Treatment of Skin Irregularities Health History Intake 

Are you over the age of 18 years?
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):
Are you of Asian heritage (Class V} and/or have a history of keloid scarring?

Cosmetic History

How would you describe your skin?
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?
Have you used Accutane in the past year?
Have you ever had any of the following injectables or implants?

Health History

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
Do you form thick or raised scars from cuts or burns?
Have you had chemotherapy in the past 6 months?
Do you have any of the following conditions
Do you have a history of Erythema Ab Igne (FM. a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?
Do you have any other health condition not mentioned here?
Have you consumed drugs or alcohol in the last 24 hours?
Have you undergone any recent surgery?
Client Name (Signature)

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