Dr. Gary E. Drake Facial Rejuvenation Center
CLIENT HEALTH RECORD
To serve you at our best, we need to know you better. Please fill out the following information. Thank You!
Date: ________________________________________ Occupation: _____________________________
Name: ____________________________________ Date of birth: ____________________________
Address: ______________________________________ City/State/Zip: __________________________
E-mail Address:__________________________________ Phone Number:_________________________
General Health
Are you currently on any medications? If so, please list here: ___________________________________
Are you pregnant? ______________________ If so, how many months? _________________________
Do you smoke? ___________ Are you currently under the care of a physician? ____________________
If so, please discuss this with your professional.
Please circle any medical problems you have or have had: Are you using/taking:
Kidney Problems
Arthritis
Accutane
Tuberculosis
Varicose
Antibiotis
Hepatitis A? B? C?
Skin Cancer/Cancer
Diabetes (II or II?)
Sunburn
Heart Problems
Tanning Beds
HIV/AIDS/Cold Sores
Skin Disease
High Blood Pressure
How does your skin react to sun exposure? ( ) Burn ( ) Sometimes Burn ( ) Rarely Burn ( ) Never Burn
Allergies:
If you have any known allergies, please list them:
______________________________________________
Are you allergic to any beauty product ( ) Yes No ( ) If so, please let us know what they are. _________
Please check if you are allergic to: ( ) Aspirin ( ) Glycolic ( ) Botanicals/Plants ( ) Fragrances
If so, please list?
________________________________________________________________________
Facial Services:
What type of skin do you believe you have? ( ) Normal ( ) Dry ( ) Oily ( ) Combination ( ) Sensitive
( ) Couperose (distended blood vessels in cheeks ( ) Rosacea ( ) Other ___________________
Does your skin break out ( ) Regularly ( ) Occasionally ( ) Never
Do you regularly have comedones (blackheads)? ( ) Yes ( ) No
Are you seeing a dermatologist? ( ) Yes ( ) No If so, why? _______________________________
What are you currently using to cleanse your face?
____________________________________________
What are you currently using to moisturize?
__________________________________________________
Are you using any special treatments (eye cream, night crème, masks)?
____________________________
What is your particular concern for your skin today?
___________________________________________
Have you previously had any of these skin procedures (treatments)?
Microdermabrasion ( ) Yes ( ) No
Chemical Peels
( ) Yes ( ) No
Phytotherapy
( ) Yes ( ) No
Laser Resurfacing ( ) Yes ( ) No If yes, ( ) IPL ( ) Co2 Fraxel (Fractional) ( ) Other – How long ago_____
Radiofrequency
( ) Yes ( ) No
Signature _______________________________________Date__________________________