Medical History Form Flawless Laser Online Medical History First Name * Last Name * Date of Birth * Address * City * Province * Postal Code * Age Phone * Email * Alberta Health Care ID Currently on Accutane, Epuris, or similar medications? * Yes No Details (optional) Any Allergies? * Yes No Details (optional) Autoimmune disease, HIV, Lupus, Hepatitis? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Blood Thinners - Baby Aspirin, Heparin, Coumadin, Warfarin, etc? * Yes No Details (optional) Breast Feeding, pregnancy or planning pregnancy? * Yes No Planning Details (optional) Cancer or post cancer treatments? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Cardiovascular problems, Heart ailments? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Cold sores or fever blisters without pre-medication? * Yes No If Yes, what is the most common cause of your cold sores? eg: sun exposure, immune response, etc Cortisone or steroid injections? * Yes No Details (optional) Dental Work? (recent or pending) * Yes No Details (optional) Diabetes Type 1 or Type 2? If yes provide diagnosis date, medication dosage and frequency and last HBA1C with Date in details field. * Yes No Details (optional) Eczema, psoriasis? * Yes No What area? (optional) Currently enlarged or painful glands? * Yes No Details (optional) Epilepsy? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Facial waxing services within 7-14 days? * Yes No Details (optional) Hypertension/high blood pressure? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Inflammatory conditions? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Keloids, pigmented scars, icepick scars, new scar tissue? * Yes No Details (optional) Recent laser procedures, chemical peels, dermabrasion, microdermabrasion? * Yes No Details (optional) Currently on light sensitive medication? * Yes No Details (optional) Lymphatic disorder, inflammation of lymph vessels, lymphedema? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Medications (including herb and supplements)? If yes provide dosage & frequency. * Yes No Details (optional) Multiple Sclerosis? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Neuromuscular Disorder? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Pacemaker or metal implants? * Yes No Details (optional) Phlebitis, varicose veins? * Yes No Details (optional) Pigmented moles, warts or growths, unidentified facial growth or mark? * Yes No Details (optional) Recent accident or serious injury? * Yes No Details (optional) Recent surgical procedure? If yes, describe. * Yes No Details (optional) Rosacea, telangiectasia/couperose? * Yes No Details (optional) Recent Retin-A, Retinol usage? * Yes No Details (optional) Skin abrasions or lesions? * Yes No Details (optional) Seizure disorder? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Stage III or IV acne? * Yes No Details (optional) Skin-lightening or bleaching agent? * Yes No Details (optional) Current sunburn? * Yes No Details (optional) Swollen or infected Tonsils? * Yes No Details (optional) Thyroid conditions? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Under medical care for an existing or suspected condition or disease? If yes, what? * Yes No Details (optional) Current viral infection, influenza? * Yes No Details (optional) Other contraindications or conditions for the technician to be aware of? * Yes No Details (optional) Previous adverse reaction to Dairy? * Yes No Previous adverse reaction to Aspirin? * Yes No Previous adverse reaction to Hydrocortisone? * Yes No Previous adverse reaction to Lidocaine? * Yes No What is your primary interest for skincare treatment? (eg: skin rejuvenation, acne, hyper-pigmentation, lines, wrinkles, etc) * Specify your areas of concern. (eg: eyes, forehead, body, etc) * I acknowledge that I am not pregnant or lactating. * Yes No I acknowledge that I have answered all questions truthfully and completely. * Yes No I acknowledge that Flawless Laser & Body Sculpting has a 24hr cancellation policy. Cancellations with less than 24 hours notice will subject to a fee of $50 per hour for every hour of treatment time that your procedure was scheduled to require. * I agree If you are human, leave this field blank. Submit
