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)


KAREN JOANNE LEWIS Professional Experience Environmental Law & Policy Center, Chicago, Illinois Environmental Business Specialist, January 1999-May 2001  Developed speaker series addressing sustainable design issues for the design and construction  Conducted research for clients, including the City of Chicago, to assist in the formulation of  Advised large commercial real

Fran Drescher was the star of a hit television series, The Nanny , when she began spotting between periods and experiencing cramping and pain after sex. The actress, then 40, paid a visit to her gyne-cologist, who dismissed the symptoms as signs of perimenopause, the stage around the onset of menopause. More than two years later, Drescher discovered the real reason menstrual periods, as

Copyright ©2018 Sedative Dosing Pdf