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Interests & History
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What Procedures Interest You?
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What would you like to achieve from your treatments
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List All Current Medications & Supplements
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Conditions you have or have had in the past
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Your Skin Care
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Have you had a facial before?
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If so; when?
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Have you had a body spa treatment before?
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If so; when?
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Which describes you when exposed to sun for 30 minutes with no SPF
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Your Ethnicity
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Do you have any skin conditions or concerns pertaining to your face or body?
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If yes; please specify
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Have you ever had chemical peels, laser, or microdermabrasion?
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If yes; please describe:
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Do you use any of the following?
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If yes, was it in the last 3 months; please describe:
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Acne Medication?
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If yes, which brand?
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What skin care products are you using?
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Have you recently used any self-tanning lotions, creams, or treatments?
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Please specify:
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Have you used any of these hair removal methods in the last 4 weeks
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What areas of concern do you have regarding your skin? (check all that apply)
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Ever had an allergic reaction to the following?
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If yes; describe:
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What SPF do you use on your face? How often/When?
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What SPF do you use on your body? How often/When?
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In the last 2 weeks, have you had and tanning bed or sun exposure?
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If so; did you burn?
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In the last 2 weeks have you had any injections such as Botox, Restylane, or Collagen?
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If yes; please specify:
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Female Patients Only
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Are you taking oral contraceptives?
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Please Specify:
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Any recent changes to or from your contraceptive treatment?
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Please Specify:
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Are you pregnant or trying to become pregnant?
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Lactating?
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Any menopause problems?
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Please Specify:
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Are you undergoing any hormone replacement therapy?
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Please Specify:
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Male Patients Only
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What is your current shaving system?
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Do you experience irritation from shaving?
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Ingrown hairs?
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Permissions for Technician
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Do you give Miranda Fuqua permission to be your Laser Technician?
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