Microdermabrasion Patient Medical History Form Page 2

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MICRODERMABRASION
PATIENT MEDICAL HISTORY FORM – Page 2
9.
Female:
Male:
Are you taking oral contraception?
Yes
No
Do you experience irritation from shaving?
Yes
No
Are you pregnant or trying to
Yes
No
Do you experience ingrown hair?
Yes
No
become pregnant?
Are you lactating?
Yes
No
SKIN CONDITIONS
1.
Do you experience breakthrough oily shine during the day?
Yes
No
2.
Do you experience breakouts regularly?
Yes
No
Occasionally
If so, where: ____________________________________________________________________________________
3.
Do you ever experience:
Flakiness
Tightness
Dryness
4.
Do you use a sunscreen?
Yes
No
Occasionally
If yes, please indicate SPF: __________________
5.
Does your skin have a tendency to redden?
Yes
No
I confirm that the information I have given is correct and that I have not withheld any information that may be relevant
to my treatment.
Client Signature

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