Health History Assessment
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3Health History Assessment
Name: ________________________________________________________ Today’s Date:____________________________
Address: ____________________________________ City: _____________________ State: _______ Zip: ________________
Date of Birth/Age: ___________________________Email Address: ______________________________________________
Home Phone: _____________________________________ Business Phone: ________________________________________
Occupation/Profession: ___________________________________________________________________________________
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Referred by:
Phone Book
Newspaper
Carolina Women
Web
Person
Symphony Directory
Radio
Other
Check the areas you wish to have treated:
Facial/Head Areas
Body Areas
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*Lip (upper)
*Neck
Eyebrows
*Sternum
Swimsuit Line
Fingers/Toes
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*Lip (lower)
*Sideburns
Nasal Bridge
*Breast
Thighs
Other
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*Chin
*Cheeks
Other
*Abdomen
Legs
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*Ears
Hairline
*Arms
Underarms
If hair growth in females in above areas noted with asterick ( * ), explain if onset was sudden or gradual and over what period of
time: __________________________________________________________________________________________________
Family members with similar hair growth patterns: _____________________________________________________________
Previous electrolysis or laser treatments: _____________________ With whom: _____________________________________
Date of first treatment: ____________________________ Date of last treatment: _____________________________________
Modality if known: ______________________________________________________________________________________
Areas treated and treatment schedule of each area: ______________________________________________________________
Aftercare used: ____________________________________ Skin reactions/healing: __________________________________
Was previous treatment successful? ________ Reason for discontinuing treatment: ____________________________________
Temporary hair removal methods previously or currently used:
Methods
Areas
Frequency
Last Used
Tweezing/E. Tweezer/Waxing
Depilatory/Shaving
Cutting
Bleaching
Other
Check, if in the past, you have had any signs on your skin:
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Swelling
Itching
Dryness
Oiliness
Pigment Changes
Check if you have had any of the following lesions on your skin:
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Acne
Eczema
Dermatitis
Psoriasis
Petechiae (red point)
Lipomas (soft lump)
Keloids
Scars
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Cancer
Boils
Blisters
Hives
Bites
Warts
Moles
Rashes
Check if you have had allergies to:
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Medicines
Cosmetics
Plants
Benzocaine
Metals
Petrolatem
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Soaps
Foods
Sun
Aloe
Other
Ever had problems with your skin healing: ________ Explain: ____________________________________________________
Use facial scrubs or abrasive sponges: __________ Areas/frequency: _______________________________________________
Ever use Retin A: _____________________ Dates/explain: ______________________________________________________
Ever use artificial tanning: _____________ Areas/frequency: ____________________________________________________
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Parent category: Medical