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)
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
Client Profile