Consult & health history form

Consultation and Health History

MEDICAL HISTORY
Are you experiencing any health problems? What oral medications are you currently using? (In the past 2-3 months) Circle your level of stress (1 low, 10 high) At any time in the present or the past have you gotten cold sore or herpes? HAVE YOU OR ANY MEMBER OF YOUR FAMILY HAD SKIN CANCER?
SKIN HISTORY
Do you have any known drug or food allergies? What level do you consider your pain threshold to be? What temperature of water do you use to cleanse? What skin care products are you using currently? Have you had any enzyme or chemical peels? Egea Spa 1521 Sherman Ave. Evanston, IL 60201 (847) 332-2772 Have you ever had a microdermabrasion treatment? What topical medications do you use or have you used? Retin-A Glycolic Acid Lactic Acid Salicylic Acid Other: Have you ever had facial plastic surgery?
VASCULARITY
SUN HISTORY
Are you going on vacation any time soon? How much time do you spend in the sun in the summer: ½ hr/day 1hr/day 2+hrs/day In the past have you lived in a sunbelt state and sunbathed? In the past have you neglected to use sun block? FREE RADICAL EXPOSURE
Egea Spa 1521 Sherman Ave. Evanston, IL 60201 (847) 332-2772  
SKIN TYPE
Does your skin ever flake or feel tight and dry? Is your skin ever shiny a few hours after cleansing? How often do you experience blackheads or blemishes? What skin type do you consider yourself to have?
WOMEN ONLY
During pregnancy, did you get hyperpigmentation or masking? Are you currently having or due for your menstrual period?
MEDICATIONS THAT ARE CONTRAINDICATED FOR LASER AND PEELS:
[ ] Antibiotics: quinolones [ie: ciprofloxacin (Cipro), Proquin, levoflaxacin (Levaquin)], tetraycyclines [ie:
Acrhomycin, doxycycline (Vibramycin, Oracea, Adoxa, Atridox & others], sulfonamides [ie: sulfamethoxazole &
trimethoprim; cotrimoxazole (Bactrim, Septra), sulfamethoxazole, (Gantanol)]
[ ] Antihistamines: diphenhydramine (Benadryl)
[ ] Malaria medications: quinine (Quinerva, Quinite, QM-260); chloroquine (Alaren), hydroxychloroquine
(Plaquenil)
[ ] Cancer chemotherapy drugs: 5-fluorouracil (5-FU, Efudex, Carac, Fluoroplex); vinblastine (Velban, Velsar);
dacarbazine (DTIC-DOME)
[ ] Cardiac drugs: amiodarone (Cordarone); nifedipine (Procardia); quinidine (Quinaglute, Quinidex); diltiazem
(Cardizem, Dilacor, Tiazac)
[ ] Diuretics: furosemide (Lasix); thiazides [hydrochlorotiazide (Hydrodiuril)]
[ ] Diabetic drugs: sulfonylureas [chlorpropamide (Diabinese), glyburide (Micronase, DiaBeta, Glynase)]
[ ] Painkillers: nonsteroidal anti-inflammatory drugs [naproxen (Naprosyn, Naprelan, Anaprox, Aleve);
piroxicam (Feldene)]
[ ] Skin medications: photodynamic therapy for skin cancer [ALA or 5-aminnolevulinic acid (Levulan),
Methyl-5-aminolevulinc acid]
[ ] Acne medications: isotretinoin (Accutane); acitretin (Soriatane)
Egea Spa 1521 Sherman Ave. Evanston, IL 60201 (847) 332-2772 [ ] Psychiatric drugs: phenothiazines [chlorpromazine (Thorazine)], tricyclic antidepressants (Norpramin),
imipramine (Tofranil)

PLEASE INDICATE IF YOU HAVE/USE ANY OF THE FOLLOWING

CONTRAINDICATED FOR:
History of coagulopathies/ thrombophlebitis Hormonal disorders stimulated by intense light Open wounds, skin injuries or recent inflammation or burns Prolonged sun exposure or artificial tanning 3-4 wks before Use of photosensitive medication and/or herbs Egea Spa 1521 Sherman Ave. Evanston, IL 60201 (847) 332-2772  
PATIENT OBJECTIVE
What areas do you want to treat and why? (Please check all that apply and be specific.)
What services would you like to learn more about? (Please check all that apply)
Egea Spa 1521 Sherman Ave. Evanston, IL 60201 (847) 332-2772

Source: http://www.egeaspa.com/wp-content/uploads/2013/07/Consult-Health-History-Form_7_22_13.pdf