Vivesse_medical_history_form_revised

Medical Aesthetic History Form
(Please Print) Patient Name: _______________________ _______________ ___ Date of Birth: __________ Age: ______ M __ F__
Please circle your answers to the questions below. Your answers will assist us in providing you with the best care possible.
Do you have an active infection, fever, flu, cold sores or cold symptoms? Yes No
Have you used medications or herbs that may cause photosensitivity (sensitivity to 515-1200 nm light exposure)? Yes No
(For example, isotretinoin (Accutane), tetracycline, St. John’s Wort, Doxycline or Retinoin)

In the 3 or 4 weeks prior to treatment, were you exposed to the sun or use artificial tanning creams or sprays? Yes No
Are you planning an event or vacation in the next 3 to 4 weeks that will expose you to the sun? Yes No
Are you pregnant or lactating? Yes No
Do you wear contact lenses? Yes No
Do you have tattoos or permanent make-up? Yes No
Do you have a history of any of the following conditions?

If you answered yes to any of the above, please provide a detailed explanation in the space below.
___________________________________________________________________________________________________________________________________________
Please list and explain other diseases or conditions you have had.
__________________________________________________________________________________________________________________________________________
Please list all medications, herbal supplements or over-the-counter medications you are taking.

___________________________________________________________________________________________________________________________________________
Do you have any Allergies or/Sensitivities?
Yes No If yes, please explain below.

___________________________________________________________________________________________________________________________________________
Have you ever been treated for a skin condition? Yes No If yes, please explain below.
__________________________________________________________________________________________________________________________________________
Have you had previous cosmetic procedures? If yes, please check appropriate box.

□ Facials/Peels □ Waxing □ Electrolysis □ Botox □ Depilatories (i.e. Nair) □ Microdermabrasion □ Laser Hair Removal
□ Photofacial □ Sclerotherapy □ Laser Spider Vein □ Dermal filler injections □ Laser facial resurfacing □ Surgery
What Type? When? _____________________________________________________________________________________________

Skin Tone: □Pale □Light Pink □Medium Pink □Light Olive □Dark Olive □Light Brown □Dark Brown □Soft Black □Black
I have obtained and read Pre and Post treatment instructions as posted on www.vivesse.net.

Patient Signature: _________________________________________________
One Barnard Lane Bloomfield, CT 06002 www.vivesse.net Phone: (860) 286-8000 or (888) 299-1110 Fax: (860) 761-2502

Source: http://www.vivesse.net/pdfs/vivesse_medical_history_form_revised.pdf