IPL Patient Questionnaire

Name:

Phone: Cell: Home: Work:

Address: City, Province, Postal Code:

Email:

Date of Birth (MM/DD/YYYY): Gender: Male / Female

Occupation:

Emergency Contact Name & Phone:

How did you hear about us:

Can we contact you through email with appointment reminders? ___ No ___ Yes Text Appointment Reminders? ___ No ___ Yes Email special promotions? ___ No ___ YesMedical History1. Check any of the following conditions or treatments you may have had: ___ Easy Bleeding/Bruising ___ High Blood Pressure ___ Heart Disease ___ Diabetes ___ Pacemaker/Defibrillator ___ Ovarian Disorder ___ Cancer ___ Hepatitis ___ Herpes Simplex/Cold Sores ___ Tuberculosis ___ Thyroid Problems ___Eye Conditions ___ Endocrine/Hormone Issues ___ HIV/AIDS ___ Epilepsy ___ Lupus ___ Immune System Disorder ____ Haemophilia ___ Autoimmune Disease (Arthritic, Celiac, etc)___ Other (please explain): 2. List any active medical problems you have:

3. Do you have any allergies? __ No __ Yes. If yes, please list:

4. What medications are you currently taking (i.e. Accutane, Antibiotics, Anticoagulants, Aspirin, Antiviral, Birth Control Pill, Iron Supplements, Gold Therapy, Hormone therapy, Coumadin, Fish Oils, Quinidine, St. John Wort, Herbal supplements, Essential oils)?

5. Please list dosage of oral antibiotics/Accutane and date of last dose taken:

6. Please list any topical medications you are using:

7. Please list any surgeries you have had:

8. Do you take Propecia or apply topical Rogaine for hair loss? __ No __ Yes

9. Do you wear contact lenses? __ No __ Yes

10. Do you have any implants, surgical plates or pins, or permanent makeup? __ No __ Yes. If yes, please list:

11. Have you ever been checked for hormone problems or have you even been seen by an endocrinologist? __ No __ Yes

12. Have you had chemotherapy in the last 12 months? __ No __ Yes

13. FEMALES ONLY. Please check all that apply: Are you pregnant? __ No __ Yes Breastfeeding? __ No __ Yes Trying to conceive? __ No __ YesPost-menopausal? __ No __ Yes Hormonal imbalance? __ No __ Yes

Dermatologic History1. What products do you use on your skin? Soap Yes / No Brand Name: Product Name: Frequency of Use: Cleanser Yes / No Brand Name: Product Name: Frequency of Use: Toner Yes / No Brand Name: Product Name: Frequency of Use: Exfoliant Yes / No Brand Name: Product Name: Frequency of Use: Mask Yes / No Brand Name: Product Name: Frequency of Use: Day Moisturizer Yes / No Brand Name: Product Name: Frequency of Use: Night Moisturizer Yes / No Brand Name: Product Name: Frequency of Use: Eye Cream Yes / No Brand Name: Product Name: Frequency of Use: Retin A / AHA Yes / No Brand Name: Product Name: Frequency of Use: Other Yes / No Brand Name: Product Name: Frequency of Use:2. Do you have any of the following skin conditions: ___ Chronic Skin Conditions ___ Photosensitivity ___ Pigmentation Disorder ___ Keloid or Hypertrophic Scar ___ Premalignant Moles ___ Skin Cancer ___ Psoriasis ___ Eczema___ Mole Removal 3. Check all conditions that apply to your skin: ___ Dry ___ Oily ____ Combination ____ Acne ____ Comedones ____ Sun Damaged ____ Scarring___ Veins ___ Wrinkles ____ Fine Lines ____ Rosaces ____ Pigmentation4. Have you had any of the following in the last 6 months: ___ Laser Skin Resurfacing ___ Chemical Peel ___ Botox Injection ___ Injection of Collagen or Dermal Filler ___ Er: YAG / CO25. What is your ethnic background?

6. When exposed to sun, you usually: ___ Always burn, never tan ___ Burn easily and tan poorly ___ Burn minimally, tan easily ___ Never burn, always tan darkly ___ Tan after initial burn ___ Rarely burn, tan dark easily 7. Do you use sunscreen regularly? ___ No ___ Yes

8. Tanning history (including direct sun, self tanners, spray tans). Please list and include last date of use:

9. Have you used any of the following in the last 12 months? ___ Accutane ___Retin A ___ Renova ___ Adapalene ___ Refissa ___ Glycolic Acid products ___ Differin ___ Hydroquinone (bleaching agent) ___ Skin Lightener 10. Please list any previous laser treatments (specify date/number of treatments/frequency/tissue response/device used, if known):

11. Have you used any of the following hair removal methods in the last 6 weeks?___ Electrolysis ___ Laser ___ Shaving ___ Chemical Depilation ___ Bleaching ___ Tweezing ___ EpilFree ___ Waxing / Threading / Sugaring12. Are you planning a holiday in the sun? __ No __ Yes. If yes, when?

Client Consent and SignatureThe information I have given is correct to the best of my knowledge, and I have not withheld any known medical state or condition. I agree that I will inform the technician before treatment if there has been any changes (i.e. if there is a change in my medication or skin care regime). I understand that the Patient Questionnaire is important to the technician so as to provide me with safe and effective IPL laser treatments.

Client Signature Date

Parent / Guardian Signature (if Client is under 18) Date

IPL MEDICAL RELEASE & CLIENT CONSENT

Please initial each of the following:

______ I understand that the IPL Laser Machine is used for hair removal and skin rejuvenation, of which I am consenting to be a patient receiving the following treatment:___________________________________________________________________________________________________________________________________________________

______ I understand that results from this treatment may vary depending on individual factors, including medical history, skin type, patient compliance with pre & post treatment instructions, and individual response to treatment.

______ I understand that due to the nature of this treatment, there is no guarantee of permanent results and maintenance treatments may be necessary in the future.

______ I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. 100% hair reduction is usually not achieved. I understand that in some rare cases, some patients may not respond to laser hair removal.

______ I understand some pain or discomfort may be experienced during treatment, but should subside shortly after the session is complete. Discomfort may be treated with the application of cool compresses or topical soothing agents.

______ I understand that there is a possibility of short-term effects such as reddening, hyperpigmentation, hypopigmentation, purpura, textural changes, scabbing, burns, blistering, erythema, whelping, temporary bruising, as well as the possibility of rare side effects such as scarring and permanent discolouration. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

______ I understand that treatments by IPL involve a series of treatments and the laser technician recommends a minimum of 4-8 laser hair removal treatments per area for all patients (regardless of any previous treatments at another facility) for best results. More sessions may be required, especially for darker skin type.

______ I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

______ I consent to taking of photographs and authorize their anonymous use for the purposes of medical audit, education, and promotion. ______ I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form

______ I confirm that I am not pregnant at this time.

______ I understand the importance of sun exposure avoidance and the use of a broad spectrum UVA/B sun block with SPF 30 or higher during the entire treatment program. I understand that tanned skin cannot be treated.

______ I understand that cold sores (herpes simplex virus) may become active due to high light exposure in those prone to them. It is recommended that Valtres or Zovirax be taken as prescribed to avoid an outbreak.

______ I have received and reviewed, with the Technician, the Pre and Post Treatment Care form. I understand that it is important to follow post treatment care carefully to minimize the chances of incomplete healing, skin textural changes, blistering or scarring. This includes, but is not limited to, avoiding sun exposure and tanning. I understand that not following the post care instructions may cause an undesirable reaction.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I consent to the service being undertaken and I hereby indemnify Serene Escapes Day Spa and its Owners & Staff from any claims whatsoever. I understand that this service is a cosmetic treatment and that no medical claims are expressed or implied. I am aware that it is my responsibility to inform the Technician of my current medical or health conditions and updating this history is essential to execute appropriate treatment procedures. I understand that there are no guarantees or refunds as to the results of this service. I hereby agree to all of the above and grant my permission to have this treatment performed on me. All information is solely collected for the internal use of Serene Escapes Day Spa and will not be shared with any third parties.

____________________________ ____________________________Printed Name Signature

____________________________ ____________________________Witness to Signature Date

Skin Typing Evaluation

Client Name: _________________________________ Date: _____________________

This information will help your laser technician to better evaluate your skin type so that your laser treatment will be more effective. Skin type is determined genetically and includes the colour of your eyes, hair, etc. The way your skin responds to sun exposure is another way of correctly assessing your skin type. Recent tanning, whether by sun or an artificial tanning booth, even tanning creams, can have a major impact on your skin.

0 1 2 3 4 ScoreWhat color are your eyes? Light Blue, Grey,

GreenBlue, Grey,

Green Blue, Hazel Dark Brown Brownish Black

What is your natural hair color? Sandy Red Blonde Chestnut, Dark Blonde Dark Brown Black

What is the color of your skin? (non -exposed areas) Pale / Reddish Very Pale Pale with Beige

Tint Light Brown Dark Brown

Do you have freckles on unexposed areas? Many Several Few Incidental None

Total for Genetic Disposition: ____________

0 1 2 3 4 ScoreWhat happens when you stay in the

sun too long?

Painful, redness, blistering,

peeling

Blistering followed by

peeling

Burns sometimes followed by

peelingBarely burns Never burns

How easily do you tan? Rarely or never Light color tan Reasonable tan Tans easily Turns dark brown quickly

Do you turn dark brown within several hours of sun exposure? Never Seldom Sometimes Often Always

How does your face respond to sun exposure? Very sensitive Sensitive Normal Very Resistant Never a problem

Total for Response to Sun Exposure: ____________

0 1 2 3 4 ScoreWhen did you last expose your

face / body to the sun? (including artificial exposure)

More than 3 months ago 2 - 3 months ago 1 - 2 months ago Less than 1

month agoLess than 2 weeks ago

Did you expose the area you intend to have treated? Never Seldom Sometimes Often Always

Total for Tanning Frequency: ____________

Total ScoreFitzpatrick Skin Type

Total for Genetic Disposition: ____________ 0 - 7 ITotal for Response to Sun Exposure: ____________ 8 - 16 II

Total for Tanning Exposure: ____________ 17 - 25 IIITotal Score: ____________ 25 - 30 IV

Over 30 V