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.
Home Address_______________________ City____________________ State___Zip Code
Which of the following best describes your skin type? (Please circle one type number)
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:
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?
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.
B) Disposiciones y Actos Alcaldía "Primero.- Cesar a D. Álvaro Marco Novillo en su cargo de VocalVecino del Grupo Municipal de Izquierda Unida en la Junta Municipal Vecino en la Junta Municipal del Distritode Ciudad Lineal. Segundo.- Nombrar a Dª Cristina Hernández Carrera Vocal Vecinadel Grupo Municipal de Izquierda Unida en la Junta Municipal delDistrito de Moncloa-Aravaca"
Mwanza Intervention Trials SUMMARY OF RESEARCH STUDIES CARRIED OUT BY THE MWANZA INTERVENTION TRIALS UNIT The Mwanza Intervention Trials Unit (MITU) builds on a long history of collaborative research on HIV and related infections in Mwanza and other neighbouring regions in North-western Tanzania. This collaboration involves the Tanzania National Institute for Medical Research (NIM