New Clients

Personal History

Your Name (required)

Email Address

Today's Date

Date of Birth

Age

Occupation

Street Address

City

State

Zip Code

Home Phone

Work Phone

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about us?

Do you sun bathe or use tanning beds? YesNo

If so, how often?

Medical History

Are you currently under the care of a physician? YesNo

If yes, please explain

Do you have any of the following medical conditions?

CancerDiabetesHigh blood pressureHerpesArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHepatitisHormone imbalanceThyroid imbalanceBlood clotting abnormalitiesAny active infection

Do you have any other health problems or medical conditions? Please list:

Have you ever had an allergic reaction to any of the following?
FoodAnimal ProteinAspirinLidocaineHydrocortisoneHydroquinone or skin bleaching agentsOther

Please describe reaction, if applicable

Medications

Please list any oral prescription medications you are presently taking

Are you taking birth control pills? YesNo

What antibiotics do you use to treat infection?

Do you take any medications for heart conditions?

Are you on any mood altering or anti-depression medication?

What topical medications or creams are you currently using?

What herbal supplements do you use regularly?

History (for our female clients)

Are you pregnant or trying to become pregnant? YesNo

Are you breastfeeding? YesNo

Are you using contraception? YesNo

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

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