Health Information
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Which concerns apply to you?
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Are you pregnant or trying to become pregnant?
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Do you use oral contraceptives?
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Are you allergic to cosmetic ingredients or foods?
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If yes, list cosmetic ingredient or food allergies
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Do you have any neuromuscular or autoimmune diseases?
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If yes, list neuromuscular or autoimmune diseases
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Do you smoke?
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If yes, how many?
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How many years?
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Do you drink alcohol?
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If yes, how much?
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Do you take Asprin, Advil, Motrin, Ibuprofen or anti-inflammatory meds more than once a week?
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If yes, please explain
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List all medications(prescription and over the counter)
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Do you have any allergies to medications?
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If yes, please specify type of reaction
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Do you take oral anti-coagulant(blood thinning) medications?
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If yes, please specify type
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Have you had any cosmetic procedures?
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If yes, please specify type
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Please list all surgeries and/or hospitalizations with dates
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Have you had any of the following:
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Please complete the following section if you are interested in: Injectables, Laser and/or Skin Care
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Skin Type
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List any topical creams, lotions or oral atibiotics taken for acne, skin cancer, anti-aging or hyperpigmentation:
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Injectables and/or Implants
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If yes and/or other, please specify type, date and body region
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Current Cosmetic Products
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List brands of cosmetic products
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Chronic Skin Disorders
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Have you had any of the following:
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Hair Removal Methods
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If yes, please specify type and body region
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If yes, what type of laser was used?
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