Medical History FormThis is a general intake form to be used for any medspa treatment or service. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastEmail *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneSex *MaleFemaleTransgenderOtherPrefer not to sayIf other, please specifyDate of BirthEmergency Contact *FirstLastEmergency Contact Phone NumberRelationship To Emergency ContactMEDICAL HISTORYAre you curently receiving medical treatment? *NoYesIf yes, please provide detailsAre you currently taking any medication? *NoYesIf yes, please provide detailsCheck if you have a history or currently have any of the following medical conditionsDiabetesThyroid DisorderHormone ImbalanceHigh Blood PressureHepatitisSkin CancerHeart ProblemsCoagulopathiesWound InfectionKeloidsHypertrophic ScarringAnemiaAIDS (HIV)HemophiliaHypoglycemiaCold SoresIron DeficiencyNoneAre you pregnant or nursingYesNoDo you have a history of HerpesYesNoHave you had Gold Therapy for Rheumatoid Arthritis?YesNoHave you had surgery recently?YesNoIf you have had recent surgery, when was it?Are you allergic to any medication? *NoYesIf yes, please provide detailsHave you recently used any special cream or medication to treat a skin condition?YesNoIf you answered yes, please explainDo you experience big mood swings, or suffer from anxiety or depression?YesNoDo you have any permanent make up or tattoos?YesNoDo you smoke?YesNoOccassionallyDo you wear contacts?YesNoDo you take diet pills?YesNoOccassionallyDo you drink caffeinated beverages?YesNoOccassionallyDo you use sunscreen?YesNoOccassionallyHow often do you drink alcohol?DailyWeeklyMonthlyRarelyNeverDo you have a pacemaker or defibrillator?YesNoDo you have metal or other implantsYesNoDo you take diuretics or laxativesYesNoOccassionallyHow much water do you drink daily?What type of skin do you have?OilyDryComboAcne proneNot sureDo you use self tanning lotions?YesNoOccassionallyWhat is your national origin?Skin type, or when exposed to the sun WITHOUT PROTECTION for about an hour:Always burns, never tansAlways burns, sometime tansSometimes burns, sometimes tansAlways tansHispanicMediterraneanMiddle EasternBlackWhen was your last significant exposure to the sun?Are you planning a vacation in the sun soon? If so, when?What methods do you have or have you used for hair removal?ShavingWaxingElectrolysisPluckingBleachingCreamsNoneHave you previously had laser treatment?YesNoHave you previously had microneedling?YesNoHave you previously had a chemical peel?YesNoHave you previously had Botox?YesNoHave you previously had Facial Filler?YesNoDo you experience skin breakouts?YesNoWhat type of skin care products are you currently using?Are there any specific issues or questions you would like us to address today?May we take photos for your personal file?YesNoIs there anything else you think we should know before your service?Medical History Terms & Conditions *This is where we'd put the full terms and conditions for this medical form. This field is marked as required and has to be ticked to be submitted.1. YOUR AGREEMENT By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box. PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.Patient/Carer/Guardian Signature * Clear Signature Date *Submit