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YOUR MEDICAL AND HEALTH HISTORY

YOUR MEDICAL AND HEALTH HISTORY

YOUR MEDICAL AND HEALTH HISTORY

FEMALES: circle

Are you pregnant?
Are you breastfeeding?
Are you planning pregnancy during the course of treatment?
During pregnancy did you develop hyper pigmentation or masking?
Are you going through menopause?

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.

Including prescription and over the counter drug
Do you have any allergies (products, medications, food)?
Any mesh metals or metal implants in body?

Answer the following question:

Are you currently treating for any medical conditions?
Have you ever seen a physician regarding your skin?
Do you have any active skin disease or infection in the area to be treated?
Do you have any skin allergies?
Have you had skin cancer or pre-cancerous lesions?
Do you have psoriasis/eczema in the area to be treated?
Are there any moles with hair in the area to be treated?
Are you allergic to latex, lidocaine, or any lotion?
Have you ever had surgery in the area to be treated?
Have you had any previous laser or skin treatments to the area to be treated?
Have you/are you using Accutane?
Are you using Retin-A, Renova, Differin, Tazorac?
Do you sunbathe?
Are you currently using, or have you used a tanning bed or self-tanner?
Do you use sunscreen?
Do you use facial depilatories or hot wax?
Does your skin remain discolored after healing from a cut?

I confirm that the answers to the questionnaire are true and correct.

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