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General Medical History Form

Name *

First

Last

(IC) Identification Number / FIN

Occupation

What are your areas of concern?

Uneven Skin Tone
Acne Scarring / Acne
Melasma
Wrinkles Dry Skin
Crow’s Feet
Dark Circles
Dull Skin
Eczema
Skin Elasticity
Sun Damage
Dehydrated Skin
Cellulite
Sagging Skin
Others

If you have selected "others" Please state here

Pain Level

High
Medium
Low

My Skin Is :

Oily
Dry
Oily & Dry
Acne Prone

Any Allergies? (Please Leave Blank If None)

Any Major Illnesses? (Please Leave Blank If None)

Current Medications? (Please Leave Blank If None)

Please indicate for all current or past conditions that apply:

High/Low Blood Pressure
Varicose Veins/Bruising Broken Bones
Epilepsy
Asthma/Medication Diabetes Type I or II Numbness/Tingling Osteoporosis
Metal Rods/Plates/Screws Hepatitis A/B/C
Heart Condition/Disease
Hemophilia/Clotting Disorder
Arthritis
Immune Disorders
Sinus Problems
HIV/AIDS
Fibromyalgia Keloid Scarring Pacemaker Sinus Problems
Anxiety/Depression
Thyroid Condition
Cold Sores/Herpes/Shingles
Staph Infection
Sprains/Strains
Sleeping/Eating Disorders
Headaches/Migraines
Lupus
Fatigue/Dizziness/Vertigo

Other Medical Conditions (Please Explain If Any)

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