"Laser Therapy Intake Form - Sonoma Vein Aesthetic & Laser Specialists"

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SONOMA VEIN AESTHETIC &
CONSULT INTAKE FORM
LASER SPECIALISTS
Date:
Name: ___________________________________________________ Date of Birth: __________
Address: _________________________________________________________________________
Home Phone: _______________________Work:_________________Cell: _____________________
Email: ____________________________________________________________________________
Preferred Method of Contact: ⃝
Email
Phone
Text
Primary Care Physician: ____________________________________________________________
How did you hear about us? ________________________________________ ___________________
Reason for Today’s Visit: ⃝ Leg or Face Veins ⃝ Skin Rejuvenation ⃝ Photo Facial ⃝ Sun Damage
⃝ Laser Hair Removal ⃝ Tattoo Removal ⃝ Other: _______________________
**The information below is necessary for your procedure. Please answer Yes or No to the following:
Personal Health History
Yes
No
___
___
Are you using any prescribed medications? If yes, please list:
** Please advise us if you are taking any of the following medications (circle those that you take):
Accutane, Adapine, Aldomet, Anafranil, Asedin, Aventyl, Benadryl, Captopril, Diltiazem, Cipro,
Desyrel, DTC-Dome, Elavil, Eulexin, Fluroplex, Folex, Gold, Lamprene, Loniten, Ludiomil, Norpramin,
Periactin, Nifedipine, Surmontil, Tetracycline, Tofranil, Velban, Vivactil
___ ___
Are you using any herbal medications? If yes, please list:
___ ___
Do you take any blood thinning medications? If yes, please list:
___ ___
Do you have an allergies to medications, cosmetics, or foods? If yes, please list:
SONOMA VEIN AESTHETIC &
CONSULT INTAKE FORM
LASER SPECIALISTS
Date:
Name: ___________________________________________________ Date of Birth: __________
Address: _________________________________________________________________________
Home Phone: _______________________Work:_________________Cell: _____________________
Email: ____________________________________________________________________________
Preferred Method of Contact: ⃝
Email
Phone
Text
Primary Care Physician: ____________________________________________________________
How did you hear about us? ________________________________________ ___________________
Reason for Today’s Visit: ⃝ Leg or Face Veins ⃝ Skin Rejuvenation ⃝ Photo Facial ⃝ Sun Damage
⃝ Laser Hair Removal ⃝ Tattoo Removal ⃝ Other: _______________________
**The information below is necessary for your procedure. Please answer Yes or No to the following:
Personal Health History
Yes
No
___
___
Are you using any prescribed medications? If yes, please list:
** Please advise us if you are taking any of the following medications (circle those that you take):
Accutane, Adapine, Aldomet, Anafranil, Asedin, Aventyl, Benadryl, Captopril, Diltiazem, Cipro,
Desyrel, DTC-Dome, Elavil, Eulexin, Fluroplex, Folex, Gold, Lamprene, Loniten, Ludiomil, Norpramin,
Periactin, Nifedipine, Surmontil, Tetracycline, Tofranil, Velban, Vivactil
___ ___
Are you using any herbal medications? If yes, please list:
___ ___
Do you take any blood thinning medications? If yes, please list:
___ ___
Do you have an allergies to medications, cosmetics, or foods? If yes, please list:
Yes
No
___
Are you allergic to eggs, cow milk protein or human albumin? If yes, please list:
___
___
Do you have any allergies to latex?
___
___
Do you have any neuromuscular or autoimmune diseases? If so, please list:
Do you have any implantable devices ? If so, please list:
Please check any health problems, past or present:
⃝ Seizures
⃝ Diabetes
⃝ Diabetes
⃝ Heart Problems
⃝ High Blood Pressure
⃝ Thyroid
⃝ Skin Cancer ⃝ Asthma
⃝ Cystic Acne
⃝ Lupus/Scleroderma
⃝ Hepatitis
⃝ Cancer
⃝ Vasovagal Syncope/Fainting
⃝ Other:
_____________________________________________________________________________________
Personal/Social History
Yes
No
___
___
Do you spend a lot of time outdoors? Hours per day?
or Per week?
Do you routinely use sunscreen? If so, SPF?
Have you ever used a tanning bed or self-tanners? Last time?
___
___
Do you smoke? How much? ______ How Long? _____ When did you quit? _____
___
___
Do you have any tattoos or permanent makeup? If so, where?
___
___
Do you have body piercings? If so, where?
Skin Health History
Yes
No
___
___
Are you using any topical creams, lotions or oral antibiotics prescribed for a skin
condition? If yes, please list:
___
___
Have you ever had any of the following injectable or implants?: ⃝ Botox/Dysport
⃝ Juvederm ⃝ Radiesse ⃝ Restaylane ⃝ Perlane ⃝ Silicone ⃝ Hylaform ⃝ Collagen
⃝ Other: _________
If so, when was it done? ___________________ What area(s) were treated: ______________________
Do you have any of the following chronic skin disorders? ⃝ Psoriasis ⃝ Fever/Sun Blisters ⃝ Cold
Sores ⃝ Keloid Scarring ⃝ Herpes Simplex/ Blisters
Have you ever undergone any of the following treatments? ⃝ Microdermabrasion ⃝ Photo Facial
⃝ Skin Tightening ⃝ Cosmetic Surgery ⃝ Accutane If yes, explain: __________________________
____________________________________________________________________________________
(Circle all that apply )
Race/Ethnicity: (This information is used to determine skin typing for particular laser procedures)
⃝ American Indian/Alaska Native
⃝ Asian
⃝ African American
⃝ Caucasian/White
⃝ Hispanic/Latino
⃝ Hawaiian/Pacific Islander
⃝ Middle Eastern
⃝ Mediterranean
⃝ Northern European ⃝ Other Race ⃝ Unknown
I verify that the above information is true and accurate to the best of my knowledge.
Signature: _____________________________________________ Date: __________________
Reviewed By: __________________________________________ Date: __________________
2014-01-02
Sonoma Vein Aesthetic & Laser Specialists
A Department of Santa Rosa Cardiology
500 Doyle Park Drive, Suite 205. Santa Rosa, CA 95405
Phone: 707-636-8346 Fax: 707-205-1008
Fitzpatrick Skin Classification
Please circle appropriate answers below
Score
Question
0
1
2
3
4
What is the color
Light Blue/
Gray
Blue
Brown
Dark Brown/
of your eyes?
Green
Black
What is the
Sandy Red
Blonde
Chestnut/
Dark Brown
Black
natural color of
Dark Blonde
your hair?
What is the color
Reddish
Very Pale
Pale with
Light Brown
Dark Brown
of your skin?
Beige Tint
(unexposed areas)
Do you have
Many
Several
Few
Incidental
None
freckles on SUN
exposed areas?
What happens
Painful
Blistering,
Burns
Rarely Burns
Never Burns
when you stay in
Redness and
followed by
sometimes,
the sun too long?
Blistering
peeling
followed by
peeling
To what degree
Hardly or not
Light color or
Reasonable
Tans very
Turn Dark
do you turn
at all
Tan
Tan
easily
Brown quickly
brown?
Do you turn
Never
Seldom
Sometimes
Often
Always
brown several
hours after sun
exposure?
How does your
Very Sensitive
Sensitive
Normal
Very
Never had a
face respond to
Resistant
problem
sun?
When did you last
Never
Hardly Ever
Sometimes
Often
Always
expose yourself to
sun?
Total Score:
Score
Fitzpatrick Skin Type
0-7
I
8-16
II
17-25
III
25-30
IV
Over 30
V-VI
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