South Coast Med Spa

Step 1: Medical History

In order to provide you with the most appropriate skin care treatment, we would appreciate your time in completing the following questionnaire. All information is strictly confidential.

PERSONAL INFORMATION
Client: First Name: A value is required. Last Name: A value is required.
Address: Street: A value is required.
City: A value is required.State: A value is required.Zip: A value is required.
Invalid format.
Contact Phone:
Home A value is required.
Invalid format.		 Work A value is required.
Invalid format.		 Cell A value is required.
Invalid format.
Birth Date (mm/dd/yy): A value is required.Invalid format. Age: A value is required. Email: A value is required.
Invalid format.

Emergency Contact Person (Name and Phone):
A value is required.

How were you referred to us?
A value is required.
MEDICAL HISTORY
Which of the following best describes your skin type?
Please make a selection.

 

Are you currently under the care of a physician?

Please make a selection.

Are you currently under the care of a dermatologist?

Please make a selection.

Do you have a history of livido reticularis, an autoimmune disease, in which the blood vessels are constricted, or narrowed resulting in mottled discoloration on large areas of the leg or arms?

Please make a selection.

Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or repeated exposure moderately intense heat or infrared irradiation?

Please make a selection.

Do you have any of the following medical conditions? (Please check all that apply)
cancer      diabetes     high blood pressure     herpes     arthritis    frequent cold sores     
HIV/AIDS     keloid scarring     skin disease/skin lesions     seizure disorder     hepatitis     
hormone imbalance     thryroid imbalance     blood clotting abnormalities     any active infection
None of the above

Do you have any other health problems or medical conditions? Please list:

What Oral medications are you presently taking?
ACCUTANE      birth control pills     hormones     
others (please list):
None of the above  

Have you ever used Accutane?

Please make a selection.
If yes, when did you last use it?

What topical modifications or creams are you currently using?
RetinaA       Others (please list):
None of the above   

Have you ever had laser hair removal?
Yes     No

Have you ever used any of the following hair removal methods in the past six weeks?
shaving     waxing     electrolysis     plucking     tweezing  stringing     depilatories
None of the above   

Have you had any recent tanning or sun exposure that changed the color of your skin?

Please make a selection.

Have you recently used any self tanning lotions or treatments?

Please make a selection.

Do you form thick or raised scars from cuts or burns?

Please make a selection.

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?

Please make a selection.

For our Female clients: Are you pregnant or trying to become pregnant?

Please make a selection.

Are you using contraception?

Please make a selection.

Are you breastfeeding?

Please make a selection.


ALLERGIES

Have you ever had an allergic reaction to any of the following? (please check all that apply and describe the reaction you experienced.)
food      latex     cosmetics     aspirin     lidocaine     hydrocortisone    
hydroquinone or skin bleaching agents     sulfa medications    
others:
None of the above 

You must agree.		 I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, physician assistant, physician, or nurse of my current medical or health conditions and to update this history as a current medical history is essential for the caregiver to execute appropriate treatment procedures.