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Indulge Aesthetics Medical Spa
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Last Name:
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First Name:
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MIddle Name:
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Address:
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City/State/Zip:
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Phone Number:
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E-mail:
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Occupation:
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Date of Birth:
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Age:
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Sex:
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Height
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Weight:
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Ideal Weight:
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Best Form of Contact
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Who may we thank for your referral?
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Emergency Contact:
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Emergency Contact Phone Number :
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Primary Healthcare Provider:
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Healthcare Provider Phone Number:
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Please specify your genetic origin:
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Females
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Are you pregnant, nursing, or possibly pregnant?
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Are you planning pregnancy during course of treatment?
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During pregnancy did you develop hyperpigmentation or masking?
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Do you have regular periods?
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Are you going through menopause?
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Medications
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Please list all medications- Prescriptions, Over the counter, Vitamins, Herbs, Supplements and reason for taking them:
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Are you taking blood thinning medications?
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Are you allergic to ay medications?
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If yes, what reaction?
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Any food allergies? ( eggs, dairy, gluten, etc.) Please specify:
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Are you allergic to latex,lidocaine,or any lotions/creams?
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Medical History ( Please check all that apply ) :
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Acne
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ALS
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Bell's Palsy
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Bleeding Disorders
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Botox/Dysport/FIllers
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Bruxism/Teeth Grinding
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Burns/ Skin Grafts
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Cold Sore/ Fever
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Depression
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Diabetes
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Eczema
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Endocrine Disorders
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Epidermolysis Bullosa
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Heart Disease
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Headaches
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Hepatitis
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High Blood Pressure
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Hirsutism
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HIV / AIDS
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Hormone Replacement
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Jaw Clenching
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Kaposi's Sarcoma
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Keloid Scars
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Lupus Erythematosus
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Metal or Other Implants
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Migraines
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Multiple Sclerosis
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Myasthenia Graves
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Pacemaker
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Permanent Makeup
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Port-Wine Stain
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Polycystic Ovary Disease
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Psoriasis
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Ramsay Hunt Syndrome
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Rosacea
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Seizures
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Shingles
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Skin Cancer
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Stroke
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Tattoos
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Thyroid Disease
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Vitiligo
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New Yes / No
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Please Answer Following Questions
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Any complications from prior Botox/Dysport/Filler/Lasers/PDO Threads?
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If yes, please specify
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Please list any other pertinent medical/surgical imformation:
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Are you currfently being treated for any medical condition?
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If yes, please specify
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Have you had any Aesthetic treatments ( Botox, FIller etc. )
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If yes, please specify
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Have you been on antibiotics in the last two weeks?
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Have you ever seen a physician regarding your skin?
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Do you have any active skin disease or infection in the area being treated?
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Do you have any skin allergies?
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Have you had skin cancer or precancerous lesions?
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Do you have psoriasis / eczema in the area being treated?
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Have you had surgrey in the area being treated?
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Have you had any previous laser treatments/ skin treatments / tattoos to the area being treated?
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If yes, please describe
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Have you used Accutane in the last six months?
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If yes, how recently?
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Are you using a prescription Retinoid ( Retin-A, Differin, Tazorac, etc. )?
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If yes, which one?
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Are you using Glycolic/ AHA / BHA skin care products?
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Which skin care products are you currently using?
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Do you smoke? ( Cigarettes or Cigars )
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Do you drink alcoholic beverages?
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If yes, how often?
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Have you sunbathed in the last four to six weeks?
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Have you had microdermabrasion, chemical peels, or laser resurfacing?
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Do you thread, tweeze, and use depilatories or hot wax?
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Do you wear contact lenses?
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Please indicate which of the following concerns you have about your skin?
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Acne
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Aged Skin
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Age Spots
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Blackheads
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Dry Skin
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Enlarged Pores
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Hair Removal
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Leg Veins
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Oily Skin
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Pigmentation
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Redness
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Rosacea
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Scars
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Sensitive Skin
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Spider Veins
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Stretch Marks
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Sun Damage
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Keloids
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Texture
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Unevenness
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Whiteheads
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Wrinkles
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Which of the following best describes your skin type?
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Skin Type
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I confirm that the answers to the questionnaire are true and correct.
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STANDING ORDER
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