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Client Health History: Radio Frequency/High Frequency Treatment of Skin Irregularities Health History Intake
Name
City
Date of Birth
State
Home/Cell Phone
Work
Address
Zip
Email
Preferred Contact : Cell
Work
Email
Emergency contact name
Phone
Relationship to you
Are you over the age of 18 years?
Yes
No
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):
1. Very fair skin; blonde or red hair; light-colored eyes; freckles common
2. Fair skinned; light hair, fight eyes
3. Very common skin type; fair; eye and hair color vary
4. Mediterranean Caucasian skin; medium to heavy pigmentation
5. IVIideastern skin; rarely sun sensitive
6. VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V} and/or have a history of keloid scarring?
Yes
No
Cosmetic History
How would you describe your skin?
Normal
Combination
Oily
Dry
When were you last exposed to the sun (including tanning beds)
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?
Yes
No
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?
Yes
No
If yes, when?
What body area(s) were treated?
Describe your experience
Have you used Accutane in the past year?
yes
No
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
Radiesse
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other
If yes. when?
What body area(s)?
Health History
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
Do you form thick or raised scars from cuts or burns?
Yes
No
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
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillato
Implanted neuro stimulators or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (FM. a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?
Yes
No
Do you have any other health condition not mentioned here?
Yes
No
If yes, please list
Have you consumed drugs or alcohol in the last 24 hours?
Yes
No
Have you undergone any recent surgery?
Yes
No
If yes, please explain
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
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. l 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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