30 E. Main Street, Lock Haven PA 17745
Tel: 570-748-6445
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Fax: 570-748-6221
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Web: www.bngaesthetics.com
Name ________________________________________Date _________ DOB: ______________
Reason for your visit:
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Laser Tattoo Removal
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Laser Liposuction (SmartLipo)
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Wrinkles or Lip Enhancement
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Skin Rejuvenation, Age Spots,
Sun Damage
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Cellulite
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Laser Vein Removal
How many years have you noticed this problem? ________________
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MicroLaserPeel / Profractional
Resurfacing
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Facial Redness / Prominent
Blood Vessels
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Stretch Marks
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Acne or Acne Scars
At what age did your skin problem begin? _____________________
Are your present skin problems getting more pronounced?
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Yes
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No
Have you ever been treated for this problem?
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Yes
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No
If yes, when? __________________
By what method? ________________________________________________________
Are you currently taking medication for your skin problem?
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Yes
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No
If yes, which medication?__________________________________________________
Are you pregnant, nursing, or planning a pregnancy soon?
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Yes
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No
Surgeries & Previous Hospitalization
Do you have a history of keloid scarring?
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Yes
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No
Have you had any allergic reactions to anesthesia?
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Yes
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No
Do you have any skin related allergies?
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Yes
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No
If yes, please specify ___________________________________________________
Do you have any allergies to medication?
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Yes
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No
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If yes, please specify ___________________________________________________
Do you have a history of:
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Heart disease
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Herpes sores
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Bruising
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Skin injury
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□
□
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Diabetes
Bleeding disorders
Dark spots after pregnancy
Skin cancer, or suspicious moles
Do you take any medication?
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Aspirin
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Hormones/contraceptives
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Thyroid medication
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Sedatives
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Cortisone
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Anti-coagulants (blood thinners)
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Appetite depressant(diet pills)
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Insulin
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Tranquilizers
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Other (please specify)_______________________
Are you taking any herbal preparations? (Vitamins, Supplements, St. John’s Wort)
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Yes
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No
If yes, list ____________________________________________________________
What is your daily consumption of alcohol? _________________________________
Do you smoke? _____ How often? _____________
What do you smoke? (circle one) Cigarettes Cigars Pipe Tobacco Other
Do you wear contact lenses?
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Yes
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No
Have you had cold sores or fever blisters?
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Yes
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No
When were you last exposed to the sun (or a tanning booth)? ______________________
Do you use chemical sun tanning lotions?
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Yes
Are you planning a holiday in the sun?
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Yes
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No
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No
Have you ever had skin resurfacing or rejuvenation or chemical peels?
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Yes
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No
Have you ever had treatments for pigmented lesions?
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Yes
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No
Prior treatment (if any) _____________________________________________________
Have you ever used Accutane, Retin A, Glycolic Acid, Alpha Hydroxy, Topical Cortisone?
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No
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Yes
If yes, List when and how often ______________________________________________
Patient Signature __________________________________ Date ____________
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