Dr. Jill Sohayda, Medical Director

Name______Today’s date______

Last First

Address______Birthdate __/__/__

City ______State ____ Zip _____ Home Phone ______

What number do you prefer to be reached at? Phone ______

Can we leave a message at this preferred number? Yes__ No__ Gender M__ F__

Age_____ Occupation______Email Address ______

Emergency Contact Name and Phone Number______

How did you hear about us? ______

Female Clients: Are you pregnant or trying to become pregnant ? Y/ N

Are you using contraception? Y / N Are you breastfeeding Y / N

What skin problems concern you the most?

Sun Damage _ Uneven Skin Tone _ Sun/Brown Spots _

Upper lip lines _ Wrinkles _ Dry patches _

Acne/Oiliness _ Blackheads/Whiteheads _ Scarring _ Unwanted hair _ Other ______

Please check all home care products that you currently use and list the brand name:

Cleanser______Toner______Moisturizer______

Night Cream______Eye Cream______Masque______

Retin-A Cream______Hydroquinone______

Vitamin C______Other______

Have you undergone any of the following treatments? (check all that apply )

Dermal fillers ( Juvederm, Restylane, Radiesse, Collagen, Sculptra) ______

Botox ______Photofacial (IPL) or Laser Skin Treatments ______

Sclerotherapy (injection of leg veins ) ______Accutane ______

Microdermabrasion ______Chemical Peel ______

Cosmetic Surgery (please list type of surgery and date) ______

List all medications that you are currently taking or have taken in the last week : ( prescription, herbal, and over the counter meds ) ______

Have you taken antibiotics in the last week? Y / N Specify ______

Are you allergic to medications? (include prescription and over the counter meds, and the type of reaction )______

Are you allergic to latex, lidocaine or any lotions? Y / N______

Are there any open wounds or infections in the area being treated? Y / N

If you are getting laser hair removal:

Are there any moles in the area being treated Y / N

Have you used a tanning bed or tanning cream in the last 6 weeks Y /N

Have you been exposed to the sun in the last 6 weeks Y / N

Do you form thick or raised scars from cuts or burns? Y / N

Medical History: ( check all that apply )

Bleeding Disorders _ Burns/Skin Grafts _ Diabetes _

Endocrine Disorders _ Epidermolysis Bullosa _ Gold Therapy _

Heart Disease _ Hemorrhoids _ High Blood Pressure _

Hirsutism _ Hormone Replacement Tx _ Implants _ Kaposi’s Sarcoma _ Keloid Scars _ Lupus _ Permanent Makeup _ Polycystic Ovarian Dx _ Precocious Puberty _ Psoriasis _ Seizures _ Shingles _

Skin Cancer _ Tattoos _ Thyroid Disease _ Vitiligo _ Port Wine Stain_

Name of your family doctor ______Phone number ______

I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to in form the technician, esthetician, therapist, nurse, 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 ______