MEDICAL HISTORY FORM
DATE OF BIRTH:
EMERGENCY CONTACT NAME & NUMBER:
Do you have or previously had any of the following: (Circle YES or NO)
YES NO History of MRSA
YES NO Diabetes
YES NO Hepatitis A B C D
YES NO Easy Bleeding/Hemophilia
YES NO Abnormal Heart Condition
YES NO Taking blood thinners such as: Aspirin/Ibuprofen/Alcohol/Coumadin etc
YES NO Pregnant/Breastfeeding
YES NO Autoimmune disorder
YES NO Cancer (Year?)
YES NO Chemotherapy/Radiation
YES NO Tumors/Growth/Cysts
YES NO Difficulty numbing with dental work
YES NO Skin diseases
YES NO Eczema
YES NO Are you prone to herpes?
YES NO Infectious diseases now/high fever now
YES NO Epilepsy
YES NO Do you have a pacemaker?
YES NO Oily Skin
YES NO Accutane or acne treatment (Completed When?)
YES NO Botox (Last treatment.
YES NO Forehead/Brow Lift/Facelift (Date of procedure?)
YES NO Chemical Peel (Last Treatment?)
YES NO Brow Lash Tinting (Last Treatment?)
YES NO Tan by booth or salon
YES NO Do you have problems with healing of wounds?
YES NO Have you consumed drugs or alcohol in the last 24 hours?
YES NO Did you undergo any surgery in the last 14 days?
YES NO Allergic reaction to any medications such as Lidocaine/Tetracaine/Epinephrine/Dermacaine/Benzyl Alcohol/Carbopol/Lecithin/Propylene Glycol/Vitamin E Acetate etc.
YES NO Allergies to metals/food etc.
YES NO Any diseases or disorders not listed
YES NO Do you use skin care products containing Retin-A/Glycolic Acid/Alpha Hydroxy?
Please list any/all medications you are taking:
I AGREE THAT ALL HE INFORMATION ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE