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Confidential Skin Health History

"*" indicates required fields

Name*

First Last

Date

MM slash DD slash YYYY

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze your skin care needs.

Personal Information:

Age

Date of Birth

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Phone

Phone best time to reach?

AM

PM

Are you a smoker?

No

Yes

Medical:

Are you on any blood thinners?

No

Yes

Do you have a pace maker?

No

Yes

Any metal implants?

No

Yes

List all medications taken:

Allergies :

Are you currently under the care of a physicians?

No

Yes

If yes, for what condition(s)?

Are you pregnant?

No

Yes

Please select any of the following you have been treated for:

Skin Disease

Acne

Cold Sores

High Blood Pressure

Diabetes

Cancer

Home Theraphy

Your daily stress level is:

Mild/Low

Medium/Average

High/Intense

How much water do you drink a day?

How often do you exercise?

Do you have any metal implants in your body?

No

Yes

If yes, where?

Ethnic Background :

Occupation :

Your Skin

On a scale of 1 to 10 (1 = Horrible, 10 Fantastic), please rate how you feel about the overall look of your skin?

How often do you wear facial sunscreen?

Everyday

Occasionally

Only when I’m outside

If you go in the sun without sunscreen, how often will you burn?

Always

Most of the Time

Sometimes

Rarely Burn

Very Rarely

I Never Burn

When was your last sunburn?

Use of tanning beds:

Daily

Once a Week

Occasionally

Never

Please list any cosmetic procedures you have had in the last 12 months

What skin care line are you using?

Describe your daily skin care routine

What is the most important improvement you would like to see in your skin?

Do you have any upcoming vacations or trips that you will be in the sun or beach for a long period of time?

No

Yes

When?

MM slash DD slash YYYY

Do you receive any of the following procedures regularly?

Waxing

Facial Injections

Microdermabrasion

Chemical Peels

Microneedling

Other

Consent

I agree

I understand the information I have provided above is true and correct. I also understand that all
information stated is strictly confidential and will not be shared outside of this facility due to
HIPPA regulations.

Email

This field is for validation purposes and should be left unchanged.

Located inside Spine and Sport Rehabilitation Institute 286 S University Dr Plantation, FL 33324

Services

Hair Restoration
Microneedling
Hydrodermabrasion
Microdermabrasion
Chemical Peels
Dermaplaning
High Frequency
Body Buffing

Questions?

Phone: 530-615-7589Email: info@pureradiancebeauty.com