CONFIDENTIAL HEALTH HISTORY QUESTIONNAIRE

Patient Name:
Date:
Date of Birth:
Age:
Male Female
Heritage/Ethnic Background:
Fitz
Address:
Zip:
Cell#
Other#
Occupation:
E-mail Address:
Emergency Contact:
Emergency Contact Cell#
E-mail Address:
How did you hear about us or Referred by?
List of Medications & Supplements:

Medical History

Pacemaker / defibrillator

Metal implants

Current or history of skin cancer/other cancer/ pre-malignant moles

Severe concurrent medical conditions (e.g. cardiac disorders)

Pregnancy and nursing

Impaired immune system

Diseases stimulated by light (e.g. Lupus, Porphyria, Epilepsy)

Diseases stimulated by heat (e.g. Herpes Simplex)

Endocrine disorders (e.g. diabetes, PCO)

Surgical Procedures

Active skin infection (e.g. psoriasis, eczema)

Skin disorders (e.g. keloids, Abnormal wound healing)

History of bleeding disorders

Use of medication / herbs inducing photosensitivity

Facial laser resurfacing / deep chemical peeling, last 3 months

Needle epilation, waxing or tweezing, last 6 weeks

Tattoo or permanent makeup

Tanned skin

Saphenous Insufficiency

Injections/fillers

List any medications taken
List any allergies
Detail any medical condition
Other considerations
Patient Signature:
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Witness:

MEDICATIONS LIST

PLEASE CHECK ANY & ALL MEDICATIONS YOU ARE CURRENTLY TAKING

Acne Meds
  • Isotretinoin (Accutane)
  • Tretinoin (Retin-A)
Anticancer
  • Chlorambucil
  • Cyclophosphamide
  • Dacarbazine
  • Fluorouacil
  • Flutamide
  • Mercaptopurine
  • Methotrexate
  • Procarbazine
  • Thioguanine
  • Vinblastine
Antidepressants
  • Amitriptyline
  • Amoxapine
  • Clomipramine
  • Doxepin
  • lmipramine
  • Isocarboxazid
  • Maprotiline
  • Phenelzine
  • Protriptyline
  • Trazadone
  • Trimipramine
Antiegileptics, Sedative Muscle Relaxants
  • Carbamazepine
  • Cyclobenzaprine
  • Diazepam
  • Meprobamate
  • Phenobarbitol
  • Phenytoin
Antihistamines
  • Azatadine
  • Clemastine
  • Diphenhydramine
  • Terfenadine
  • Tripelennamine
Antihygertensives
  • Captopril
  • Dilitiazem
  • Methyldopa
  • Minoxidil
  • Nifedipine
Antimicrobials
  • Ciprofloxacin
  • Clofazimine
  • Dapsone
  • Demeclocycline
  • Doxycycline
  • Enoxacine
  • Flucytosine
  • Griseafulvin
  • Ketoconazole
  • Lomefloxacine
  • Methacycline
  • Minocycline
  • Nalidixic acid
  • Nanfloxacin
  • Ofloxacin
  • Oxytetracycline
  • Pyrazinamide
  • Sulfa drugs (Bactrim, Septra, Tetracycline)
Antigarasitics
  • Bithionol
  • Chloroquine
  • Pyruvinium pamoate
  • Quinine
  • Thiabendazole
Antigsychotics
  • Chlorpromazine
  • Chlorprothixene
  • Fluphenazine
  • Haloperidol
  • Perphenazine
  • Prochlorperazine
  • Promethazine
  • Thioridazine
  • Thiothixane
  • Trifluoperazine
  • Thioflupromazine
  • Trimeprazine
Cardiovascular
  • Amiodarone
  • Atenolol
  • Captopril
  • Diltiazem
  • Disopyramide
  • Nifedipine
  • Propranolol
  • Quinidine gluconate
  • Quinidine sulfate
  • Verapamil
Diuretics
  • Acetazolaminde
  • Amiloride
  • Bendroflumethiazide
  • Benzthiazide
  • Chlorothiazide
  • Furosemide
  • Hydrochlorothiazide
  • Hydro flumethiazide
  • Methyclothiazide
  • Metalazone olythiazide
  • Quinethazone
  • Trichlormethia-zide
Hygoglycemics
  • Acetohexamide
  • Chlorpropamide
  • Glipizide
  • Tolazamide
  • Tolbutamide
  • NSAIDS
  • Diclofenac
  • Fenoprofen
  • Flurbiprofen
  • Indomethacin
  • Ketoprofen
  • Meclofenamate
  • Naproxen
  • Phenylbutazone
  • Piroxicam
  • Sulindac
Others
  • Bergamot oil
  • Oils of citron, lavender, lime, sandalwood
  • Benzocaine
  • Clofibrate
  • Oral contraceptive
  • Etretinate
  • Gold salts
  • Hexachlorophene
  • Lovastatin
  • St John’s Wort
  • Gmethylcoumarin (used in perfumes, lotions, etc)

Patient Signature

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Witness

Date

CLIENT SERVICE AGREEMENT

I, herby agree that all information given is correct to my ability and not withheld any known information. I give my consent and authorization for any photographs to be taken for the sole purpose of viewing the progress of my professional treatments and educational purposes. I understand that these photos will not be used for any publication without my consent.

I also understand that the services offered are not a substitution for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the clinician in giving better service and is completely confidential.

Signature:
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