Microdermabrasion Patient Medical History Form

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DERMATOLOGY PARTNERS OF THE NORTH SHORE, L.L.C.
MICRODERMABRASION
PATIENT MEDICAL HISTORY FORM – Page 1
Date of Initial Visit_____________________________________ Esthetician ________________________________________
Name_______________________________________________ Occupation ________________________________________
Address _____________________________________________Telephone: _________________________________ (Home)
City/State_____________________________________________
______________________________ (Work/Cell)
Age:
21 years & under
21 to 30
31 to 40 years
41 to 50 years
Over 50 years
The following profile must be completed for all clients having Microdermabrasion treatments. This form is completely
confidential and will be used to evaluate your special needs and concerns.
1.
Briefly describe what your cosmetic concerns are and what results you would like to achieve. ____________________
______________________________________________________________________________________________
2.
What made you consider Microdermabrasion and how did you hear about us? ________________________________
______________________________________________________________________________________________
CLIENT HISTORY
1.
Are you currently (or have been within the last year) under a physician’s care ?
Yes
No
2.
Have you undergone any surgery in the last nine months?
Yes
No
If yes, please specify: _____________________________________________________________________________
3.
Have you had any of these health problems in the past or currently?
Cancer
Heart problems
Tuberculosis
Rosacea
Diabetes
Thyroid
Hepatitis
Epilepsy
Hormone imbalance
Herpes, tendency to cold sores
Liver disease
HIV or other immune deficiency disorder
4.
List medications and vitamins that you take regularly: ___________________________________________________
______________________________________________________________________________________________
5.
Are you allergic to any medications?
Yes
No
If yes, please specify: _________________________________
Other allergies: __________________________________________________________________________________
6.
Do you smoke?
Yes
No
Do you exercise regularly?
Yes
No
Have you ever had a chemical peel?
Yes
No
Do you get regular sleep
Yes
No
Do you use Retin-A/Differin?
Yes
No
Do you wear contact lenses?
Yes
No
Have you used Accutane/ hydroquinone?
Yes
No
Do your wounds heal poorly
Yes
No
Are you on aspirin therapy?
Yes
No
or slowly?
7.
Do you have any special skin problems on your face?
Yes
No
If yes, please specify _____________________________________________________________________________
Do you have any special skin problems on your body?
Yes
No
If yes, please specify _____________________________________________________________________________
8.
What types of skin care products do you currently use?
Soap
Toner
Masque
Other: ____________________________________________
Cleanser
Moisturizer
Scrub/peel?
_________________________________________________

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