Claritymedicalspa.net

530-842-3261 • [email protected] 106 Ranch Lane • Suite B • Yreka, CA 96097 Please review problems and select the treatment options you are interested in.
IPL (Intense Pulsed Light)Laser Skin Resurfacing Laser Lesion RemovalExcision of Skin Tags 530-842-3261 • [email protected] 106 Ranch Lane • Suite B • Yreka, CA 96097 Current Skin Care Regime:___________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Do you tan regularly: YES NO Do you use a self Tanner? YES NO Any History of abnormal pigment with pregnancy/contraceptives? YES NO Keloid Scars? YES NO Do you use sunscreen YES NO Brand and SPF:______________________ Reapply throughout the day? YES NO cosmetic treatment historyPrevious Dermal Fillers: YES NO Type of filler if known _______________________________ Date of last treatment: _______________________________________________ What area was injected ____________________________ Any adverse events? _________________________________________________ Which one and how many units used, if known: ____________________________________ Date of last treatment? ______________ What are was injected? __________________________________ Any adverse events? ___________________________________________ other preVious cosmetic treatments (Peels, Microdermabrasion, Laser, Surgery?)Treatment ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Patient Signature:________________________________________________________________________________________________________ Printed name:____________________________________________________________________________________________________________ 530-842-3261 • [email protected] 106 Ranch Lane • Suite B • Yreka, CA 96097 meDical historyPrimary Care Physician: ___________________________________________________ Phone Number: ______________________________ Dermatologist: _____________________________________________________________ Phone Number:_______________________________ Autoimmune or Immune Disorder Including HIV Please detail any of above and list any additional medical problems past or present, prior surgeries, and hospitalizations. May also use back of page.
______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Patient Signature:________________________________________________________________________________________________________ Printed name:____________________________________________________________________________________________________________ 530-842-3261 • [email protected] 106 Ranch Lane • Suite B • Yreka, CA 96097 Do you Smoke? YES/NO Packs per day? ___________ Did you smoke previously? YES/NO Year Quit: ______________ Number of alcoholic beverages per day: _________ Number of caffeinated beverages per day: ____________________________ Hours of Exercise per week: __________________ Anti-inflammatory (Advil, Aleve, Celebrex, etc.) other meDications: Include mg dose and frequency taken/per day (may also use back side of page)______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Dietary supplements______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ allergies Please provide a detailed list of any reactions or sensitivities to both medications and foods.
______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Patient Signature:________________________________________________________________________________________________________ Printed name:____________________________________________________________________________________________________________ 530-842-3261 • [email protected] 106 Ranch Lane • Suite B • Yreka, CA 96097 Circle the number that best describes you. In order to provide the most safe and effective treatment, please complete the information below as accurately as possible. Ethnic origin is closest to:1. Very fair skin (Celtic and Scandinavian)2. Fair-skinned (Caucasian with light hair and light eyes)3. Pale-skinned (Caucasian with dark hair and dark eyes)4. Olive-skinned (Mediterranean, some Asian, some Hispanic)5. Dark-skinned (Middle Eastern, Hispanic, Asian, some African)6. Very dark-skinned (African) Natural hair color at age 18 was:0. Red1. Blonde2. Light brown3. Dark brown4. Black Color of skin that is not normally exposed to sun:0. Pink to reddish1. Very pale2. Pale with beige tint3. Light brown4. Medium to dark brown5. Dark brown to black If I go out in the sun for an hour without sunscreen and haven’t been in the sun in weeks, my skin will:0. Burn, blister and peel1. Burn, then when the burn resolves there is little or no color change2. Burn, then turns tan quickly3. Get pink, then turns to tan quickly4. Just tan5. My skin gets darker6. My skin is so dark i can’t tell When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artificial tanning cream?0. Longer than one month ago1. Within the past month2. Within the past two weeks3. Within the past week Help us improve. List other services you would like us to offer.
Patient Signature:________________________________________________________________________________________________________ Printed name:____________________________________________________________________________________________________________

Source: http://www.claritymedicalspa.net/forms/pt_info.pdf