Sonoran Medical Centers
Laser Treatment Questionnaire
Patient name:__________________________________
Do you have any tattoos?  No  Yes If yes, please list
location: ____________________________________
_____________________________________________
Have you received laser treatment before?  No  Yes
DOB:________________ Date: ___________________
Home Phone: (_____)______________________
Area(s) to be treated today:_______________________
If yes, please list when you had it done, what you had
done and how your skin reacted to the treatment.
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Allergies:  Drug  Make-up  Food  Skin
Have you ever received a cosmetic peel/cosmetic
Please list: _______________________________
procedure before?  No  Yes If so, please list when
Medications you are currently taking and the dosages:
you had it done, what you had done and how your skin
(Please include any antibiotics, birth control pills, iron
reacted to the treatment._________________________
supplements, gold therapy, coumadin, herbal
_____________________________________________
supplements and oral or injectable steroids.)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Do any of your meds cause sensitivity to sun?
Previous unwanted hair removal history, if applicable.
 No  Yes __________________________________
Please check all that apply
Are you, or have you ever used Retin-A or Accutane?
 Wax epilation  Electrolysis  Bleaching  Shaving
 No  Yes Dates:____________________________
 Nair, Epilstop  Nothing
Do you have a history of any autoimmune disease or an
 Mechanical epilation (tweezing) Where do you tweeze
immune disorder that would impair your healing
and how often? ________________________________
process? Please describe:________________________
Are you prone to genital herpes break outs?
 No  Yes
Cold Sores?  No  Yes
Do you have any venereal diseases?  No  Yes If
so, what are they? ______________________________
Are you pregnant?  No  Yes Due Date: _________
In order of Importance, please rank your interest in the
following (low 1 2 3 4 5 high)
Reduction of lines and wrinkles:
______
Reduction of Brown spots/sun damage/hyper
pigmentation:
______
Reduction of oil/acne:
______
Acne scars diminished:
______
Reduction of redness/ rosacea:
______
Do you have a history of Keloids/Hypertrophic Scars?
 No  Yes
When a scar appears on your skin is it significantly dark
in color?  No  Yes
What is your hair type?  Coarse  Fine
What is your skin type?  Oily  Normal  Dry
 Sensitive  Combination
What are you hoping to improve with your skin?
_____________________________________________
_____________________________________________
Do you have any implants/injectables/permanent makeup?  No  Yes If so, please list:_________________
_____________________________________________
Please answer yes or no for the following
Are you currently using moisturizer?
 No  Yes
Do you use SPF daily?
 No  Yes
Do you wear contact lenses?
 No  Yes
Do you do facials at home?
 No  Yes
* We do not recommend laser therapy if any of the below
conditions exist. Please check any conditions that
describe your current health.
_______ Pregnancy
_______ Nursing females
_______ Photosensitivity disorders
_______ Herpes (active)
_______ Shingles (active)
_______ Seizure disorders triggered by light
_______ Bacterial infections
Comments___________________________________