aquasalonandspa.net

Aquasalonandspa.net

MEDICAL HISTORY
CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment, we need you to complete the
following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Home Address_______________________ City____________________ State___Zip Code Which of the following best describes your skin type? (Please circle one type number)
MEDICAL HISTORY

Are you currently under the care of a physician? Yes
Are you currently under the care of a dermatologist? Yes 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? Yes No 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 Thyroid imbalance Blood clotting abnormalities Any active infection 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) Food Latex Aspirin Lidocaine Hydrocortisone
Hydroquinone or skin bleaching agents Others:

MEDICATIONS
What oral medications are you presently taking? Birth control pills Hormones
Others (Please list):
Are you on any mood altering or anti-depression medication? Have you ever used Accutane? Yes No, If yes, when did you last use it? What topical medications or creams are you currently using? Retin-A® Others (Please list): What herbal supplements do you use regularly?
HISTORY
Have you ever had laser hair removal? Yes No
Have you used any of the following hair removal methods in the past six weeks?
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin? Yes No
Have you recently used any self-tanning lotions or treatments? Yes No
Do you form thick or raised scars from cuts or burns? Yes No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)
or marks after physical trauma? Yes No If yes, please describe:
For our female clients:
Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No
Are you using contraception? Yes No

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, doctor or nurse 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.

Source: http://www.aquasalonandspa.net/medical_forms/medical-history.pdf

Zweitanschreiben telef. tew

IRT, Limburgstr. 16 a, 81539 München Sehr geehrte/r Entwöhnungswillige/r, wir freuen uns, dass Sie sich entschieden haben, an unserer telefonischen Tabakentwöhnung teilzunehmen und somit den Weg in die Rauchfreiheit mit uns zusammen gehen. Wie bereits angekündigt, senden wir Ihnen hiermit ein paar Fragebögen zu, um das weitere Vorgehen individuell auf Ihre Voraussetzungen und Bed�

hollandparksurgery.co.uk

PATIETS REPREENTATIVE GROUP NEWS LETTER (PRG) H o l l a n d P a r k S u r g e r y T e l : 0 1 9 2 2 6 0 4 5 0 0 PRG Members JEFF POWELL. BRIAN STRINGER. ESTELLE POWELL. LILLIAN ADDIS. DIANE JONES. CHRISTINE BLADON. ERIC WINDSOR. LESLEY BLOXHAM. KEN REYNOLDS. VALERIE SYLVSTER -SMITH. MAGGIE BENNETT. ALAN MORGAN. DR STEVENS. PHIL GENDER. The PRG terms of ref