SKIN HEALTH HISTORY
Name: ________________________________ Date of Birth:____________ Gender: M  F 
Address:_____________________________________________________________________________
City: _____________________________________ State: ________________ Zip: _________________
Day phone: ________________ Evening phone: ________________ Cell phone: __________________
Email:______________________________________________________________________________
Emergency Contact (name & number): ___________________________________________________
Referred By: _________________________________________________________________________
PATIENT OBJECTIVE:
Please describe your skin concerns for today’s visit _________________________________________
____________________________________________________________________________________
If there were 2 things you could improve about your skin, what would they be?
____________________________________________________________________________________
____________________________________________________________________________________
What results do you wish to achieve? _____________________________________________________
____________________________________________________________________________________
What is important to you when deciding on treatment?
_____________________________________________________________________________________
YOUR HEALTH
List any and all over the counter or prescription medications, that you currently take:
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you exercise regularly? Y  N 
Do you wear contact lenses? Y  N 
Do you smoke? Y  N 
Are you claustrophobic? Y  N 
Do you have metal implants or a pacemaker? Y  N 
Do you participate in vigorous aerobic activity or sports? Y  N 
Do you get Cold Sores/Fever Blisters Y  N 
(date of last breakout) _________________________
What is your current stress level:  low  average  high  extremely high
MEDICAL CONDITIONS (please check all that apply)
__Diabetes __Epilepsy __Glaucoma __High Blood Pressure __Heart Disease __Hormone Imbalance
__Keloid scarring __Kidney Disease __Liver Disease __Mental Illness __Migraines __Rosacea
__Seizures ___Spinal Injury ____Stroke __Tuberculosis __Thyroid Disease __Vitiligo ___Eczema
___Psoriasis ___Dermatitis ____Warts ____Skin Tags
Other :____________________________________________________________________________
ALLERGIES (please check all that apply)
__Cosmetics __Sunscreens __ Benzoyl Peroxide __Hydroxy acids __Hydroquinone __Iodine
__Fragrance __Sulphur __Copper __Retinoids __Latex __Metals __Animals __Pollen __Food
__Dairy/Lactose __Citrus __Alcohol __Aspirin __Ibuprofen __Amoxicillin or Pencillin
___ Lidocaine, Tetracaine or Benzocaine
Other Allergies:______________________________________________________________________
If yes, please explain your reaction (i.e., rash, hives, shortness of breath,etc.)
____________________________________________________________________________________
YOUR SKIN (please check all that apply)
__Dry __Sensitive __ Rough __ Dull __Flaky__ Tight __Freckles __ Uneven/blotchy __ Sun damaged
__Redness__ Sallow __ Hyperpigmented __ Hypopigmented __Dehydrated __Oily
__ Large pores __Active acne __ Blackheads __ Whiteheads __Cystic Acne __Thick skin __ Thin skin
__ Saggy skin __Fine lines __ Wrinkles __Crows feet __Forehead lines __Deep folds around mouth
__Facial Veins __Irritated __Moles/Skin Tags __Acne scars __Under eye circles __Droopy eyelids
__Under eye bags __ Lip lines __Thin Lips__ Cellulite __ Leg veins __Stretch marks
__Excessive Sweating__ Unwanted facial hair __Unwanted body hair
Do you have any special skin problems pertaining to your face or body? Y  N 
If yes, please specify:______________________________________________________
PREVIOUS TREATMENTS: (please check all that apply)
___Facials ___Laser Resurfacing ___Chemical Peel ___Microdermabrasion ____TCA Peel
___Laser Hair Removal ___Botox or Dysport ___Dermal Fillers, if yes which ones:______________
___IPL/photo-facial ___Radio Frequency/Thermage ____Plastic Surgery ____
Other: ____________________________________________________________________________
Were you happy with the results? Y  N 
If not, please describe: ________________________________________________________________
YOUR CURRENT SKIN CARE REGIMEN: (please check all that apply)
___Cleanser Brand: ___________________________________________________________________
___Toner Brand: _____________________________________________________________________
___Skin lightener Brand:_______________________________________________________________
___Topical vitamin C Brand:_____________________________________________________________
___Eye Cream Brand:__________________________________________________________________
___Moisturizer with sunscreen Brand:_____________________________________________________
___Moisturizer without sunscreen Brand:__________________________________________________
___Over the counter acne products Brand:_________________________________________________
___Prescriptions used for facial rejuvenation Brand:________________________________________
___Prescription acne medications Names of Rx’s:
____________________________________________________________________________________
___Accutane if yes, what strength and date of last use:_______________________________________
___Retin-A - if yes, what strength and date of last use:_______________________________________
Other:_______________________________________________________________________________
SUN EXPOSURE/TANNING HABITS
When you go out in the sun do you:
____Always Burn ____Usually Burn ____Sometimes Burn ____Rarely Burn ____Never Burn
What percentage of time do you spend in the sun? _________________________________________
When was the last time you received significant sun exposure? _______________________________
Do you go to tanning booths? Y  N 
If yes, how long ago__________________________________
Have you used self-tanning creams or lotions? Y  N 
If yes, how long ago was the last application?______________________________________
Do you use Sunscreen? Y  N  If yes, what SPF________
MELANIN REACTIVITY:
Eye Color: _________________________________________________________________________
Natural Hair Color: __________________________________________________________________
Natural Skin tone: ___________________________________________________________________
What is your ethnic background? (examples: Irish, Scottish, Black, Hispanic, Chinese, etc.)
__________________________________________________________________________________
Have you ever experienced hyperpigmentation (darkening of the skin) as a result of a minor burn?
YN
If yes, please explain:_________________________________________________________________
FOR WOMEN ONLY
Are you taking oral contraception? Y  N 
Are you menopausal? Y  N 
Are you pregnant, trying to become pregnant, or lactating? Y  N 
Are you using Hormone Replacement Therapy? Are you menopausal? Y  N 
Do you experience acne flare-ups that seem related to your menstrual cycle? Y  N 
QUESTIONS FOR THOSE CONSIDERING LASER HAIR TREATMENTS
What facial or body areas would you like to have treated? ____________________________________
What color is the hair you want to have treated? ____________________________________________
What methods of hair removal have you used in the area/areas to be treated within the last month?
__________________________________________________________________________________
I confirm (to the best of my knowledge) that the answers I have given in regards to my medical history,
known allergies and current prescriptions I am currently ingesting orally or applying topically, and that
my answers are correct and that I have not withheld any information that may be relevant to the
treatment of my skin.
PATIENT SIGNATURE:__________________________________ DATE:____________________
Printed Name:_________________________________________________________________
Shape Wellness Center
Consent for Aesthetic Treatment
I elect today to undergo this treatment/facial/peel after the nature and purpose of the treatment has
been explained to me by___________________________________________. Although is it impossible
to list all potential risk or reaction, I have been informed of the possible effects and benefits. I
understand that I may require further treatments of the treated area to obtain the expected results at
an additional cost. I have read and understand the post care instructions and understand that it is very
important that I follow those instructions. In the event I need further post care or have any questions
post treatment, I will consult the Aesthetician immediately. I do not hold the Aesthetician whose
signature appears above or Shape Wellness Center responsible of any conditions that were present, but
not disclosed at the time of treatment or skin care procedure, which may affect the treatment today.
Please Initial and read thoroughly:
____ I agree to avoid direct sun exposure for 48 hour
____ I do not have active cold sores
____I will notify my Aesthetician at Shape Wellness Center of any concerns
____I have not taken Accutane in the past year
____I agree not to wax for 7 days post treatment
____I agree not to use Retin-A products 5 days post treatment
____I understand the possible allergic reaction notification if I do so
____I agree to apply SPF for the 48 hours when exposed to any sun
PATIENT SIGNATURE:__________________________________ DATE:____________________
Printed Name:_________________________________________________________________
Cancellation & No Show Policy
Please be advised that Shape Medical Wellness Center has a 24 hour Cancellation
Policy. If you need to change or cancel your appointment, you must do so at least 24
hours before your scheduled appointment. If appointments are missed same day, the
following action will occur:
No-show Appointments Same Day: $50.00 charge to your account each time.
Please be sure to schedule your appointments accordingly.
Signature_____________________________ Date____________________
Credit Card #__________________________________Exp._____________
Zip code associated with card:____________ Security Code
*** Please Note that your card will not be charged to make an appointment, it is simply
kept on file for appointment no show/cancellation proc