CLIENT INFORMATION AND MEDICAL HISTORY
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All
information is kept strictly confidential. PLEASE PRINT CLEARLY
PERSONAL HISTORY
First Name: _________________________ Last Name: __________________________ Date: ___________________________
Address: ________________________________________________________________
City: ___________________________ State: ____________ Zip: __________________
Phone Number: _________________________________ Do you wish to be confirmed by email or by telephone? ________________
Email: _____________________________________ Date of Birth: _________________
How did you hear about Urban Allure? ________________________________________
Does your job require you to work outdoors?
Y
N
MEDICAL HISTORY
Please be sure to fill this part out completely and honestly. This will help us treat you safely and appropriately. Please check all that
apply.
__ History of herpes (oral and/or genital)
__ Seizure disorder
__ Blood clotting abnormalities
__ Bleeding disorder/bleed easily/Bruise easily
__ Hepatitis
__ Active infections
__ Artificial Joints/Valves/Other ‘hardware’
__ Skin cancer or history of
__Arthritis
__ Hormone/Endocrine/Thyroid imbalance
__ Reaction to local anesthetics
__ Polycystic Ovarian Syndrome
__ Diabetes (type I or II ) (if yes, is it controlled? ___)
__ Pigmentation disorder/History of keloid (raised) scarring
__ Skin disease/Skin lesions
__Hearing Aid
__ HIV/AIDS
__ Pacemaker or Defibrillator
Do you have any other health problems or medical conditions? If so, please list: ___________________________________________
____________________________________________________________________________________________________________
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you
experienced) __ Food __ Latex __ Aspirin __ Lidocaine __ Hydrocortisone __ Hydroquinone (or other skin bleaching agents)
__ Others Iodine __ Tape__ Band-Aids__
Do you have any medication allergies? ______________________________ Reaction (if applicable): _________________________
Is this your first cosmetic procedure: _______
Are you currently having other cosmetic procedures at another spa/clinic/MD office? If so, what procedure(s): __________________
MEDICATIONS
What oral medications are you presently taking? __ Birth Control Pills __ Hormones
Others (Please list):____________________________________________________________________________________________
Are you currently on any mood altering or anti-depression medications? _________________________________________________
Have you ever used Accutane? __ Yes __ No
If yes, when did you last use it?_______________________________________
What topical medications or products are you currently using or have used in the past? Retin-A, Renova, Adapalene, Hydroxyl Acid
or Retinol/Vitamin A derivative products? Others (Please list): ______________________________
What herbal supplements do you use regularly? _____________________________________________________________________
LASER CLIENTS
Have you ever had laser hair removal? __ Yes
__ No
Have you used any of the following hair removal methods in the past 6 weeks?
__ Shaving __ Waxing __ Electrolysis __ Plucking __Tweezing __ Stringing
__ Depilatories (Nair)
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical
trauma? __ Yes __ No If yes, please describe: ___________________________________________________________________
Skin Typing
Please circle the number that describes your skins first reaction to sun exposure. If you are not sure, please ask for a skin typing
questionnaire.
1. Fair skin. Always burns. Never tans.
2. Fair skin. Usually burns. Tans less than average.
3. Fair skin. Sometimes mild burns. Tans average.
4. Moderate brown skin. Rarely burns. Usually tans.
5. Dark brown skin. Rarely burns. Tans almost always.
6. Very dark skin. Never burns. Deeply pigmented.
SKIN CARE CLIENTS
1) Have you ever had a facial treatment before? No__ Yes__ If Yes, when? ____
2) Do you have any special skin problems or concerns pertaining to your face or body? Yes__ No__ If Yes, explain______________
3) Have you ever had chemical peels, laser or microdermabrasion? Yes__ No___ If Yes, when? ___
4) Have you used an acne medication? Yes__ No__ When?___ Which drug?________
5) What skin care products are you currently using?
Cleanser____________________Toner________________________Mask_________________Eye Product____________________
Moisturizer________________________Scrubs___________________________Night Cream______________________________
What areas of concern do you have regarding your skin (please check all that apply)
Breakouts/acne ___
Wrinkles/fine lines___
Uneven skin tone____
Rosacea___
Blackheads/whiteheads___
Dull/dry skin___
Sun damage___
Broken capillaries__
Excessive oil/shine___
Flaky skin___
What SPF do you use on your face? ______
Redness___
Dehydrated___
Sun spot/liver spots___
Other_______________
How often/when?_______
Have you ever received Botox, Restylane or Collagen injections? Yes __
No__ If so, when? ______________
What would you like to achieve from your treatment today? ______________________________________
What are your skin care goals? ____________________________________________________________
FOR OUR FEMALE CLIENTS
Are you pregnant or trying to become pregnant? __ Yes
Are you using contraception? __ Yes __ No
__ No
Are you breastfeeding? __ Yes
__ No
Please list any other information or concerns you may have regarding your treatment here at Urban Allure: _____________________
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility
to inform the doctor or nurse of my current medical or health conditions and to update this history. A current medical history is
essential for my caregiver to execute the appropriate treatment procedures.
Signature ___________________________________________________________________ Date: ________________________