Download client health record - the Facial Rejuvenation Center Medical Spa

Dr. Gary E. Drake Facial Rejuvenation Center
CLIENT HEALTH RECORD
To serve you at our best, we need to know you better. Please fill out the following information. Thank You!
Date: ________________________________________ Occupation: _____________________________
Name: ____________________________________ Date of birth: ____________________________
Address: ______________________________________ City/State/Zip: __________________________
E-mail Address:__________________________________ Phone Number:_________________________
General Health
Are you currently on any medications? If so, please list here: ___________________________________
Are you pregnant? ______________________ If so, how many months? _________________________
Do you smoke? ___________ Are you currently under the care of a physician? ____________________
If so, please discuss this with your professional.
Please circle any medical problems you have or have had: Are you using/taking:
Kidney Problems
Arthritis
Accutane
Tuberculosis
Varicose
Antibiotis
Hepatitis A? B? C?
Skin Cancer/Cancer
Diabetes (II or II?)
Sunburn
Heart Problems
Tanning Beds
HIV/AIDS/Cold Sores
Skin Disease
High Blood Pressure
How does your skin react to sun exposure? ( ) Burn ( ) Sometimes Burn ( ) Rarely Burn ( ) Never Burn
Allergies:
If you have any known allergies, please list them:
______________________________________________
Are you allergic to any beauty product ( ) Yes No ( ) If so, please let us know what they are. _________
Please check if you are allergic to: ( ) Aspirin ( ) Glycolic ( ) Botanicals/Plants ( ) Fragrances
If so, please list?
________________________________________________________________________
Facial Services:
What type of skin do you believe you have? ( ) Normal ( ) Dry ( ) Oily ( ) Combination ( ) Sensitive
( ) Couperose (distended blood vessels in cheeks ( ) Rosacea ( ) Other ___________________
Does your skin break out ( ) Regularly ( ) Occasionally ( ) Never
Do you regularly have comedones (blackheads)? ( ) Yes ( ) No
Are you seeing a dermatologist? ( ) Yes ( ) No If so, why? _______________________________
What are you currently using to cleanse your face?
____________________________________________
What are you currently using to moisturize?
__________________________________________________
Are you using any special treatments (eye cream, night crème, masks)?
____________________________
What is your particular concern for your skin today?
___________________________________________
Have you previously had any of these skin procedures (treatments)?
Microdermabrasion ( ) Yes ( ) No
Chemical Peels
( ) Yes ( ) No
Phytotherapy
( ) Yes ( ) No
Laser Resurfacing ( ) Yes ( ) No If yes, ( ) IPL ( ) Co2 Fraxel (Fractional) ( ) Other – How long ago_____
Radiofrequency
( ) Yes ( ) No
Signature _______________________________________Date__________________________