ART DIRECTOR • GRAPHIC DESIGNER
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PAMELA DUNN
ART DIRECTOR • GRAPHIC DESIGNER
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CONTACT
CLIENT HEALTH HISTORY : MicroNeedling
CLIENT HEALTH HISTORY : MicroNeedling
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Email
*
Preferred Contact
Cell
Work
Email
Emergency Contact
*
First Name
Last Name
Relationship
Emergency Contact Phone
*
(###)
###
####
Are you over the age of 18 years?
*
Yes
No
SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?
Yes
No
Please list the products you use regularly:
Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors
Cosmetic History
Have you had needling or collagen induction therapy in the past?
Yes
No
If yes, what area was treated?
Are you prone to keloid or hypertrophic scarring?
Yes
No
Have you ever had any of the following injectables or implants?
Botox
Juvederm
Radiesse
Restylane
Perlane
Silicone
Collagen
Sculptra
Dysport
Other
If yes, when?
What body area(s)?
Have you had any recent cosmetic surgeries/procedures?
Yes
No
If yes, when?
What body area?
Have you used Accutane in the past year?
Yes
No
When were you last exposed to the sun (including tanning beds)?
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
Do you have any tattoos in the area to be treated?
Yes
No
Health History
Have you had chemotherapy in the past 6 months?
Yes
No
Do you have any of the following conditions:
Psoriasis
Eczema
Dermatitis
Pregnancy and/or Breastfeeding
Autoimmune Disease
Herpes Simplex
Diabetes
Heart Disease and/or Heart Defects
Hemophilia
Collagen Vascular Disease
Active Acne
If yes, please list
Do you have any other health condition not mentioned here?
Yes
No
If yes, please list
Do you have moles/skin growths in the area to be treated?
Yes
No
Have you ever had a reaction at the dentist or any other time from numbing?
Yes
No
Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Yes
No
If yes, please list
Have you consumed drugs or alcohol in the last 24 hours?
Yes
No
Please list all vitamins and supplements including herbal remedies you take regularly:
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly:
Is there anything else you would like us to know?
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 esthetician of my current medical or health conditions and to update this his-tory. A current medical history is essential to execute appropriate treatment procedures.
*
Yes
Thank you!