Client Medical Information Form

Please select all that apply:

Have you had any aspirin or blood thinning products within the last 7 days?

Any mood altering drugs within the last 8 hours? (i.e. Wellbutrin, Xanax, Prozac)

Medication, including immunosuppressive, such as anti-inflammatory or steroids?

Are you taking any vitamins or nutritional supplements?

Have you had any permanent makeup procedures before?

Did you have any reaction to tattoos or permanent makeup?

Did you have problems with healing?

Do you have a tendency to scar?

Are you currently undergoing radiation or chemotherapy?

Are you currently using Retin-A or "Alpha Hydroxy" skin care products?

Are you required to take antibiotics during dental or invasive medical procedures?

Do you exercise?

Do you wear contact lenses?

Do you have tooth fillings?

Do you have withdrawal from caffeine products?

Do you have history of skin diseases or remarkable skin sensitivities?

Are you pregnant or nursing?

Are you on hormone replacement therapy?

Are you presently taking birth control pills?

ALLERGIES. Have you had any allergic reaction to any of the following?

Have you had any of the following done in the last 30 days? Please select all that applies:

HOME CARE. What skincare products are you currently using at home? Please select all that applies:

Please select if you are currently using or have used in the past any of the following:

Please select all that apply:

Do you sunbathe or participate in outdoor activities?

Have you had direct sun exposure in the last 14 days?

Do you use tanning beds?

Have you used a tanning booth or received a spray tan in the last 14 days?

Do you feel your skin is sensitive?

FITZPATRICK SCALE. When exposed to sun, do you:

I. Very fair. Always burns. Cannot tan.

II. Fair. Usually burns. Sometimes tans.

III. Medium. Sometimes burns. Usually tans.

IV. Olive. Rarely burns. Tans easily.

V. Brown. Rarely burns. Tans easily.

VI. Dark Brown. Never burns. Always tans.

Please select the box if you hav or had experienced any of the following conditions:

Client Medical History Form