Sonoran Medical Centers

Sonoran Medical Centers

Laser Treatment Questionnaire

Patient name:______

DOB:______Date: ______

Home Phone: (_____)______

Area(s) to be treated today:______

______

Allergies:  Drug  Make-up  Food  Skin

Please list: ______

Medications you are currently taking and the dosages: (Please include any antibiotics, birth control pills, iron supplements, gold therapy, coumadin, herbal supplements and oral or injectable steroids.) ______

______

Do any of your meds causesensitivity to sun?

 No  Yes ______

Are you, or have you ever used Retin-A or Accutane?

 No  Yes Dates:______

Do you have a history of any autoimmune disease or an immune disorder that would impair your healing process? Pleasedescribe:______

Are you prone to genital herpes break outs?

 No  Yes Cold Sores?  No  Yes

Do you have any venereal diseases?  No  Yes If so, what are they? ______

Are you pregnant?  No  Yes Due Date: ______

Do you have a history of Keloids/Hypertrophic Scars?

 No  Yes

When a scar appears on your skin is it significantly dark in color? No  Yes

What is your hair type?  Coarse  Fine

What is your skin type? Oily  Normal Dry

Sensitive  Combination

What are you hoping to improve with your skin?______

Do you have any implants/injectables/permanent make-up?  No  Yes If so, please list:______

______Do you have any tattoos? No  Yes If yes, please list location:______

______Have you received laser treatment before?  No  Yes If yes, please list when you had it done, what you had done and how your skin reacted to the treatment. ______

______

Have you ever received a cosmetic peel/cosmetic procedure before?  No  Yes If so, please list when you had it done, what you had done and how your skin reacted to the treatment.______

______

Previous unwanted hair removal history, if applicable. Please check all that apply

 Wax epilation  Electrolysis Bleaching  Shaving  Nair, Epilstop  Nothing

 Mechanical epilation (tweezing) Where do you tweeze and how often? ______

In order of Importance, please rank your interest in the following (low 1 2 3 4 5 high)

Reduction of lines and wrinkles:______

Reduction of Brown spots/sun damage/hyper pigmentation: ______

Reduction of oil/acne: ______

Acne scars diminished: ______

Reduction of redness/ rosacea: ______

Please answer yes or no for the following

Are you currently using moisturizer?  No  Yes

Do you use SPF daily?  No  Yes

Do you wear contact lenses?  No  Yes

Do you do facials at home?  No  Yes

* We do not recommend laser therapy if any of the below conditions exist. Please check any conditions that describe your current health.

______Pregnancy

______Nursing females

______Photosensitivity disorders

______Herpes (active)

______Shingles (active)

______Seizure disorders triggered by light

______Bacterial infections

Comments______