CLIENT INFORMATION FORM

Please complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY

Client Name ___________________________________________________________ Date _________________

Date of Birth ________________ Age ______ Occupation _____________________________________________

Home Address _____________________________ City ____________________ State ______ Zip Code _______

Home Phone ( ) Work/Cell Phone ( )_______________________________

Email Address ________________________________________________________________________________

Emergency Contact Name and Phone Number _______________________________________________________

How were you referred to us? ____________________________________________________________________

What services are you interested in: o Laser Hair Removal o Botox o Facials
o Microdermabrasion o Skin Tightening o Detox Foot Bath o Skin Rejuvenation
oHormone Testing o Juvederm o Fat Dissolving o Weight Loss
o Nutritional Counseling o Massage Therapy o Chemical Peels

Ethnicity Type – Please check all that applies: o Hispanic o White Caucasian o Asian
o African American o American Indian o Eastern Indian
* This information helps us determine the correct laser and products to use on your skin

Which of the following best describes your skin type? (Please circle one number type)
I Always burns, never tans
II Always burns, sometimes tans
III Sometimes burns, always tans
IV Rarely burns, always tans
V Brown, moderately pigmented skin
VI Black Skin
Do you regularly use tanning salons or sun bathe? __________________ How often? ________________________

MEDICAL HISTORY
Are you currently under the care of a physician? o Yes o No
If yes, for what: _______________________________________________________________________________
_____________________________________________________________________________________________

Are you currently under the care of a dermatologist? o Yes o No

If yes, for what: ________________________________________________________________________________
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated
exposure to moderately intense heat or infrared irritation? o Yes o No

Do you have any of the following medical conditions? (Please check all that apply?)
o Cancer o Diabetes o High blood pressure oArthritis oFrequent cold sores
o HIV/AIDS o Herpes o Keloid scarring o Skin disease/Skin lesions

Do you have any other health problems or medical conditions? Please List: ________________________________
_____________________________________________________________________________________________

Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction
you experienced) o Food o Latex o Aspirin o Lidocaine o Hydrocortisone o Hydroquinone or skin
bleaching agents o Other: _____________________________________________________________________
_____________________________________________________________________________________________

Please check all that applies to you:

Do you have a pacemaker? o Yes o No

Do you have any metal surgical implants? o Yes o No
Have you been diagnosed with any autoimmune disease? o Yes o No
Are you taking Accutane or any sun-sensitive medication? o Yes o No
Are you on chemo or radiation? o Yes o No
Do you have a history of seizures? o Yes o No
Do you have a history of cold sores or herpes virus? o Yes o No
Do you take aspirin on a regular basis OR take any blood thinners? o Yes o No
Do you have a thyroid condition? o Yes o No
Do you have a hormone condition? o Yes o No
Do you have a history of numbness on any part of your face or body? o Yes o No
Are you allergic to Xylocaine or Novacaine? o Yes o No
MEDICATIONS
Do you have a history of keloid scarring? o Yes o No
What oral medications are you presently taking? o Birth Control o Hormones o Others (Please list): ___
_____________________________________________________________________________________________

Are you on any mood altering or anti-depression medication? ___________________________________________

Have you ever used Accutane? o Yes o No If yes, when did you last use it? _________________________
What topical medications or creams are you currently using? o Retin-A o Others (Please list): __________
_____________________________________________________________________________________________

What herbal supplements do you use regularly?

_______________________________________________________

HISTORY
Have you ever had laser hair removal? o Yes o No
Have you used any of the following hair removal methods in the past six weeks?
o Shaving o Waxing o Electrolysis o Tweezing o Threading oDepilatory Creams

Have you had any recent tanning or sun exposure that changed the color of your skin? o Yes o No
Have you recently used any self-tanning lotions or treatments? o Yes o No
Do you form thick or raised scars from cuts or burns? o Yes o No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after
physical trauma? o Yes o No If yes, please describe: ______________________________________________
_____________________________________________________________________________________________

Are you pregnant or nursing? If yes, how far along: ___________________________________________________

I certify that the proceeding medical, personal, and skin history statements are true and correct. I am aware that
it is my responsibility to inform the technician, esthetician, therapist, or doctor of my current medical or health
conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate
treatment procedures.

Signature____________________________________________________ Date:____________________________
 Fitzpatrick Skin Type Form
Score 0 1 2 3 4

What color are your light blue, blue, gray or blue dark brown brownish
eyes? gray, green green black
What is the natural sandy red blond chestnut/ dark brown black
color of you hair? dark blond

What is the color of reddish very pale pale with beige light brown dark brown
your skin (non- tint
exposed areas)?
Do you have freckles many several few incidental none
on unexposed areas?

ï Total score for Genetic Disposition

Score 0 1 2 3 4

What happens when painful redness blistering, burns sometimes rarely burns never burns
you stay too long in blistering, peeling followed by followed by
the sun? peeling peeling

To what degree do you hardly or not at light color tan reasonable tan tan very easy turn dark
turn brown? all brown quickly
Do you turn brown within never seldom sometimes often always
several hours of exposure?
How does your face very sensitive sensitive normal very resistant never had a
react to the sun? problem

ï Total score for reaction to sun exposure

Score 0 1 2 3 4

When did you last expose more than 3 2-3 months 1-2 months less than a less than 2
your body to sun (or months ago ago ago month ago weeks ago
artificial sunlamp/ tanning
cream)?

Do you expose the area never hardly ever sometimes often always
to be treated to the sun?
ï Total score for tanning habits

Summary
ï Total score for genetic disposition

ï Total score for reaction to sum exposure

ï Total score for tanning habits

ï Skin type score Your Fitzpatrick Skin Type

Skin Type Score Fitzpat
0-7
8-16
17-25
25-30
Over 30