Consent for light based treatment

MEDICAL HISTORY FORM
Last Name: ______________________________________ First Name: ___________________________ Address: _______________________________________________________________________________ City: ______________________________ State: _________________ Postcode: ___________________ Telephone: Home: _________________ Work: _________________ Mobile: _______________________ Date of Birth: ______________________ Sex: Female _____ Male _____ Emergency Contact: ______________________________________ Email Address: _____________________________@__________________________________________________ Area’s interested for treatment ________________________________________________________________ Please answer all of the following questions
1. Do you have ANY current or chronic medical illnesses?
Disclose any history of heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness. Please List: _____________________________________________________________________ _______________________________________________________________________________ 2. Do you have ANY current or chronic skin conditions?
Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition. Please List: _____________________________________________________________________ _______________________________________________________________________________ 3. Are you currently under a doctor’s care? If so, for what reason? 4. Do you take/use ANY medications (prescriptions and nonprescriptions), vitamins,
herbal or natural supplements, on a regular or daily basis?
Please List: _____________________________________________________________________ _______________________________________________________________________________ 5. Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis? Please List: _____________________________________________________________________ 6. Do you take/use ANY systemic/oral steroids (e.g., prednisone, dexamethasone)?  7. Do you have ANY allergies to medications, foods, latex or other substances?
Please List: _____________________________________________________________________ 8. (For women) are you or could you be pregnant? 9. (For women) are menstrual periods regular? Have you ever been diagnosed with Polycystic Ovarian Disorder? 10. Do you have a history of herpes I or II in the area to be treated? 11. Do you have a history of keloid scarring or hypertrophic scar formation? 12. Do you have a history of light induced seizures? 13. Do you have any open sores or lesions? 14. Do you have any history of radiation therapy in the area to be treated? 15. In the last six (6) months, have you used any of the following: anticoagulants or blood-thinning medications; photosensitizing medications; or anti-inflammatory or blood thinning medications? Please List product name and date last used: ___________________________________________ _______________________________________________________________________________ 16. In the last three (3) months, have you used any of the following products: glycolic acid or otheralphahydroxy or betahydroxyacid acid products exfoliating or resurfacing products or treatments?  Please List product name and date last used: _______________________________________ ________________________________________________________________________________ 17. Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers, including, but not limited to, collagen, autologous fat, Restylane® , etc.?  If yes, please list locations on or in the body and dates: ____________________________________ ___________________________________________________________________________ 18. Do you have or have you ever had any Botulinums, such as Botox® or Dysport® ?  If yes, please list locations on or in the body and dates: ________________________________ _________________________________________________________________________________ 19. Have you taken Accutane®(or products containing isotretinoin) in the last 12 months?  20. Have you taken Tretinoin (like Retin- 21. Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6 weeks? Signature: ________________________________________Date: _______________________ Ella Bache Woodlands
skin&beauty@galleria
skin&beauty@subiaco

DISCLAIMER: This sample consent form is for general information purposes only and not intended as legal advice. Palomar does not make
any representation, guarantee or warranty, express or implied or assume any liability or responsibility for the accuracy, completeness, or
usefulness of the contents of this sample form. You should consult your own attorney for legal advice
Patient Name: __________________________________________ Date: _______________________
Score: ______________________
What is your eye color?
What is the natural color
of your hair?
What is the color of your
skin (unexposed areas)?
Do you have freckles on
sun-exposed areas?
What happens when you
stay in the sun too long?
To what degree do you
turn brown?
Do you turn brown several
hours after sun exposure?
How does your face
respond to the sun?
When did you last expose
yourself to the sun, tanning
bed or self-tanning creams?
How often is the area you
want to have treated
exposed to the sun?
Add
above
Match your total score
Fitzpatrick
with the corresponding
Skin Type
for Total
skin type.

Source: http://www.skinbeautygroup.com.au/Artwork/medhistoryform.pdf