YOUR MEDICAL AND HEALTH HISTORY YOUR MEDICAL AND HEALTH HISTORY YOUR MEDICAL AND HEALTH HISTORY Last Name * First * Middle Street Address * City * State Zip * Home Phone Cell * Work FEMALES: circle Are you pregnant? Yes No Are you breastfeeding? Yes No Are you planning pregnancy during the course of treatment? Yes No During pregnancy did you develop hyper pigmentation or masking? Yes No Are you going through menopause? Yes No Complete the following items of your medical history. List and check all that applies.Always inform us of any change in your medical history and/or medication. Acne Diabetes High Blood Pressure Permanent Makeup Seizures Pacemaker Bleeding Disorder Endocrine Disorder Hirsutism PCOS Shingles Pemphigus Vulgaris Botox / Filler injections Epidermolysis Bullosa Hormone Replacement Port-wine Stain Skin Cancer Bullous Pemphigoid Burns/skin grafts Gold Therapy Implants Precocious Puberty Tattoos Ehler Danlos Cold Sores Heart Disease Kaposi’s Sarcoma Psoriasis Thyroid Disease Connective tissue disorder Herpes Lupus (SLE , DLE) Rosacea Vitiligo Medications Including prescription and over the counter drug Do you have any allergies (products, medications, food)? * Yes No If Yes Any mesh metals or metal implants in body? * Yes No If Yes Past surgical history Answer the following question: Are you currently treating for any medical conditions? Yes No Have you ever seen a physician regarding your skin? Yes No Do you have any active skin disease or infection in the area to be treated? Yes No Do you have any skin allergies? Yes No Have you had skin cancer or pre-cancerous lesions? Yes No Do you have psoriasis/eczema in the area to be treated? Yes No Are there any moles with hair in the area to be treated? Yes No Are you allergic to latex, lidocaine, or any lotion? Yes No Have you ever had surgery in the area to be treated? Yes No Have you had any previous laser or skin treatments to the area to be treated? Yes No Have you/are you using Accutane? Yes No Date of last use Are you using Retin-A, Renova, Differin, Tazorac? Yes No Concentration % Date of last use Do you sunbathe? Yes No Date of last sun exposure Are you currently using, or have you used a tanning bed or self-tanner? Yes No Date Do you use sunscreen? Yes No Do you use facial depilatories or hot wax? Yes No Does your skin remain discolored after healing from a cut? Yes No I confirm that the answers to the questionnaire are true and correct. Print Name * Date * Signature * Clear Staff Signature Clear Date If you are human, leave this field blank. Submit