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Microsoft word - urbansolutions client profile new.doc

Client Profile
Please answer all questions to the best of your ability. Please print clearly. You must fill out
this form completely before your consultation.
Name: _______________________________________Date: _________________________
City: _______________ State:____________zipcode_______________
Home Phone: ( )_______________ Cell Phone: ( ) __________________________
Business Phone: ( )_____________________________
In case of emergency, please contact:
Phone: ( )____________________ Cell Phone: ( ) _______________________

What cosmetic improvements you would like to see in your skin?
What skin treatments are you interested in?_____________________________________
How did you hear about us?____________________________________________ Lifestyle
Do you smoke cigarettes? Y or N How often?________ Packs/day?______ Do you drink alcohol? Y or N How much per day?___________________________________________________ Do you smoke marijuana or use other recreational drugs? Y or N Do you exercise? Y or N How often per week?___________________________________________________ What is your water intake (glasses per day)?________________________________ How many hours do you sleep per night?__________________________________ Stress Level: High_____________ Medium_____________ Low______________ Medical History
Please check if you have, or ever had any of the following:
Skin cancer, or pre-cancer____ HIV____ Herpes____Lupus____ Hormonal Disorder____Cold Sores____Diabetes____Irregular Periods____ Anemia____ Dermatitis____Polycystic ovary syndrome____ Hepatitis____ Keloids____Methemoglobinemia____Jaundice____Liver disease____ Abnormal blood pressure____Heart disease____ Thyroid condition____ Epilepsy____Psychiatric care____Nervous disorder____ Is there any other information about your health that we should know? ____________________________________ Are you pregnant or breastfeeding?_________________________________ List any other health or medical conditions you have:___________________________________ ______________________________________________________________________________ Are you currently using any oral, injectable, or skin medications? Y or N If so, please list.___________________________________________________________________________ Have you ever had gold injections? Y or N Are you allergic to latex? Y or N Do you have any food or medicine allergies? Y or N If so, please list.___________________________________________________________________________ Are you taking Aspirin, Motrin, Aleve, OTC or prescription medications? Y or N If so, please list: ________________________________________________________________ Are you taking Accutane? Y or N Have you taken Accutane in the last six months? Y or N Side-Effects of Accutane? ______________________________________________________________________ Do you use Birth Control? Y or N If so, please list?__________________________________________________________________________ Skin History and Profile
Please check if you have any of the following skin conditions:
Oily____ Dry____ Sensitive____ Combination____ Keloids____
Cystic Acne____ Razor Bumps____ Dark Spots____ Sun Damage____
Scalp Problems____
Describe Your skin: __________________________________________________________
Age skin problem started? _____ Acne in family?__________________________
Do you pick at your skin lesions (i.e. Acne, razor bumps)?___________________
What is your daily skin care regimen? What skin products are you using?
Do you wear make-up?_____ What brand?___________________________________________
Have you ever had a bad reaction to a skin product or procedure? Y or N
If so, what happened? ___________________________________________________________
Have You Received Treatment From a Medspa or Dermatologist? Y or N
If so, what treatment?
Have you tanned in the last 4 weeks? Y or N
Urban Skin Solutions, or any of their employees or agents, is not liable for
damages resulting from conditions, facts, or circumstances not provided in
response to the above questions.
Signature Date:_____________
Parent/Legal Guardian Signature(if under 18)


Oakdale health form for

WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE? OR, DID YOU HEAR OF US FROM : INTERNET / YELLOW PAGES / SIGN / NEWSPAPER / OTHER: AFTER COMPLETING ALL PAGES OF THIS QUESTIONAIRE PLEASE READ AND SIGN THE AUTHORIZATION AND RELEASE BELOW: I certify that I have read, understood and accurately completed the personal, medical and dental question-naires to the best of my knowledge and have not k

Microsoft powerpoint - 08benny.ppt [compatibility mode]

Stable Free Radical Assisted Peroxide Vulcanisation: Cure characteristics and vulcanisate properties Benny George and Rosamma Alex Rubber Technology Division Advanced Center For Rubber Technology Rubber Research Institute of India Kottayam, Kerala, India. IRC & IRRDB Meeting, 29 October to 2 November 20012, Kovalam, Kerala Vulcanisation Viscous raw rubber

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