Alani Medical Spa Medical History and Information
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- Julie Stokes
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1 Alani Medical Spa Medical History and Information Birth date: _/_/_ SS#/_/_ _ Today s Date: _/_/_ Name: (Mr.) (Mrs.) (Miss) Home Address: _ Work Address: _ Home Phone: ( ) Work Phone: ( ) _ Phone Number on which you would like to be contacted: ( ) _ Employer: Occupation: _ How did you hear about us? Are you now or have you been under the care of a physician within the last two years? If yes, please provide Physician s Name Address _phone number. () Person to contact in an emergency _ (_) _ Name Phone No. Address: _ List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane:
2 Medical History Form (continued) List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams): Have you recently undergone a skin peel? What products do you use for skin care? Do you have or have you had any of the following conditions (answer Yes or No): Abnormal Heart Condition Cold Sores Herpes Simplex Hemophilia High or Low Blood Pressure Prolonged Bleeding Circulatory Problems Epilepsy Diabetes Fainting Spells/Dizziness Cataracts Glaucoma Dry Eye Corneal Abrasions Eye Surgery or Injur Blepharoplasty (eyelid surgery) Visual Disturbances Cancer Tumors/Growths/Cysts Chemotherapy/Radiation Are you pregnant? Hepatitis Do you wear contact lenses? Do you use tobacco products? Are you using any eye drops or other ocular medications? Have you ever experienced hyper pigmentation from an injury? Are you currently taking aspirin or ibuprofen? Are you HIV positive? (Optional; only used to help us better determine your treatment settings) Ethnic background_ Spa Policies 1. Professional consultation is required before initial dispensing of products 2. DISCOUNTS AND PROMOTIONS - Coupons: cannot be used on already discounted treatments/services or retail products. Points/Rewards: once expired, points will not be reinstated. It is the client s responsibility to inquire about the expiration date of your points. Points cannot be used on already discounted treatments/services or retail products. 3. Gift Certificates: purchased at a discounted price cannot be used on already discounted treatments/services or retail products. 4. We do not give cash refunds. I fully understand and agree to the above Spa Policies _ Signature Date
3 Alani Medical Spa COSMETIC INTEREST QUESTIONNAIRE Health issues of interest to you (please check all that apply): [ ] BOTOX Cosmetic [ ] Acne (Botulinum Toxin Type A) [ ] Sunscreen advice [ ] Skin care products [ ] Removing leg veins [ ] Skin rejuvenation [ ] Facials and eye treatments [ ] Laser resurfacing [ ] Spider vein treatments [ ] Removing facial veins [ ] Birthmarks [ ] Retina-A or Renova [ ] Liver spots/age spots [ ] Micro-dermabrasion [ ] Laser Hair reduction [ ] Other, pleases specify: Please complete the following sentence with the statement that most accurately reflects your feelings: When looking at my face in the mirror; [ ] I believe I look younger than my true age [ ] The same as my true age [ ] Older than my true age When looking in the mirror; [ ] I am not concerned about the appearance of my wrinkles. [ ] Somewhat concerned about the appearance of my wrinkles [ ] Very concerned about the appearance of my wrinkles
4 COSMETIC INTEREST QUESTIONNAIRE (continued) How did you hear about us? [ ] My physician (full name) [ ] My insurance company provider [ ] The yellow pages (specify advertisement) [ ] A friend or family member (name) [ ] Another person not listed above (name) Please provide the name and address of the person who referred you so we can thank them: [ ] An article or advertisement in [ ] Internet [ ] A seminar where I saw the doctor. The event took place on (date): At (location):
5 Skin Typing Matrix Name: Please answer the following questions by circling the number which best describes you. Your clinician will total your score during the consultation. My ethnic origin is Very fair (Celtic and Scandinavian) Closest to: Fair-skinned Caucasians with light hair and light eyes Pale-skinned Caucasians with dark hair and dark eyes Olive-skinned (Mediterranean, some Asian, some Hispanic) Dark-skinned (Middle Eastern, Hispanic, Asians, some Africans) Very dark-skinned (African) My eye Color is: Light blue 0 Blue / Green 1 Green / Gray / Golden 2 Hazel / Light brown 3 Brown 4 My natural hair color Red 0 At age 18 was: Blonde 1 Light brown 2 Dark brown 3 Black 4 The color of my skin that Pink to reddish 0 Is not normally exposed to Very Pale 1 Sun is: Pale with a beige tan 2 Light brown 3 Medium to dark brown 4 Dark brown - black 5 If I go out into the sun Burn, blister and peel 0 For an hour or so without Burn, then when burn resolves there is little or no color change 1 Sunscreen and have not Burn, but then turns to tan in a few days 2 Been out in the sun Get pink, but then turns to tan quickly 3 For weeks, my skin will: Just tan 4 Just gets darker 5 My skin color is so dark I can't tell 6 When was the last time Longer than one month ago 0 The area to be treated was Within the past month 1 Exposed to natural sunlight, Within the past two weeks 2 Tanning booths or artificial Within the past week 3 Tanning cream? Total Score: If your score is: Your skin type is:
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If you have had Permanent Makeup previously done and fail to tell us, Elena reserves the right to refuse service and may recommend removal Her signature hair stroke technique will not work over dark, solid,
The Aesthetic and Wellness Center, PLC
Dear DealSaver Member: Welcome to The Aesthetic and Wellness Center. You have taken advantage of a great bargain. We hope you have a wonderful experience with us and you are satisfied with the results