Client History - Essex Med Spa

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Dr. Jill Sohayda, Medical Director
Today’s date______
Birthdate __/__/__
City ____________State ____ Zip _____
Home Phone ________________
What number do you prefer to be reached at?
Phone ________________
Can we leave a message at this preferred number? Yes__ No__ Gender M__ F__
Age_____ Occupation_______________ Email Address _____________________
Emergency Contact Name and Phone Number______________________________
How did you hear about us? ________________________________
Female Clients: Are you pregnant or trying to become pregnant ? Y/ N
Are you using contraception? Y / N
Are you breastfeeding Y / N
What skin problems concern you the most?
Sun Damage _
Uneven Skin Tone _
Sun/Brown Spots _
Upper lip lines _
Wrinkles _
Dry patches _
Acne/Oiliness _
Blackheads/Whiteheads _ Scarring _
Unwanted hair _
Other ______________________________
Please check all home care products that you currently use and list the
brand name:
Cleanser____________ Toner_________ Moisturizer_______________
Night Cream________ Eye Cream____________ Masque___________
Retin-A Cream_____________
Vitamin C____________ Other__________________________________
Have you undergone any of the following treatments? (check all that apply )
Dermal fillers ( Juvederm, Restylane, Radiesse, Collagen, Sculptra) _________
Botox _______
Photofacial (IPL) or Laser Skin Treatments _________
Sclerotherapy (injection of leg veins ) ______
Accutane __________
Microdermabrasion _________
Chemical Peel __________
Cosmetic Surgery (please list type of surgery and date) ___________________
List all medications that you are currently taking or have taken in the last
week : ( prescription, herbal, and over the counter meds )
Have you taken antibiotics in the last week? Y / N Specify _____________
Are you allergic to medications? (include prescription and over the counter
meds, and the type of reaction )_____________________________________
Are you allergic to latex, lidocaine or any lotions? Y / N_________________
Are there any open wounds or infections in the area being treated? Y / N
If you are getting laser hair removal:
Are there any moles in the area being treated
Have you used a tanning bed or tanning cream in the last 6 weeks
Have you been exposed to the sun in the last 6 weeks
Do you form thick or raised scars from cuts or burns?
Y /N
Medical History: ( check all that apply )
Bleeding Disorders _
Endocrine Disorders _
Heart Disease _
Hirsutism _
Kaposi’s Sarcoma _
Permanent Makeup _
Psoriasis _
Skin Cancer _
Vitiligo _
Burns/Skin Grafts _
Epidermolysis Bullosa _
Hemorrhoids _
Hormone Replacement Tx _
Keloid Scars _
Polycystic Ovarian Dx _
Seizures _
Tattoos _
Port Wine Stain_
Diabetes _
Gold Therapy _
High Blood Pressure _
Implants _
Lupus _
Precocious Puberty _
Shingles _
Thyroid Disease _
Name of your family doctor _______________Phone number _______________
I certify that the preceding medical, personal, and skin history statements are
true and correct. I am aware that it is my responsibility to in form the technician,
esthetician, therapist, nurse, or doctor of my current medical or health conditions
and to update this history. A current medical history is essential for the caregiver
to execute appropriate treatment procedures.
Signature __________________________
Date _______________