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: _________________________ DOB:____________________ Address:______________________________________________________________________ City: _______________ State:____________zipcode_______________ Home Phone: ( )_______________ Cell Phone: ( ) __________________________ E-Mail:_________________________________________________________________ Employer:______________________Occupation:_____________________________________ Business Phone: ( )_____________________________ In case of emergency, please contact: _____________________________________Relation__________________________________ 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? (i.e.Neutrogena):________________________________________________________________ ______________________________________________________________________________ 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)
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
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
Client Profile