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Client Medical History Form
Date of Birth
Please select all that applies:
Have you had any aspirin or blood thinning products within the last 7 days?
Any mood altering drugs within the last 8 hours? (i.e. Wellbutrin, Xanax, Prozac)
Medication, including immunosuppressive, such as anti-inflammatory or steroids?
Are you taking any vitamins or nutritional supplements?
Have you had any tattoos, or permanent makeup procedures before?
Did you have any reaction to tattoos or permanent makeup?
Did you have problems with healing?
Do you have a tendency to scar?
Are you currently undergoing radiation or chemotherapy?
Are you currently using Retin-A or "Alpha Hydroxy" skin care products?
Are you required to take antibiotics during dental or invasive medical procedures?
Do you exercise?
Do you wear contact lenses?
Do you have tooth fillings?
Do you have withdrawal from caffeine products?
Do you have history of skin diseases or remarkable skin sensitivities?
Are you pregnant or nursing?
Are you on hormone replacement therapy?
Are you presently taking birth control pills?
ALLERGIES. Have you had any allergic reaction to any of the following?
Fish or Marine
Skin care products
Any metal (e.g. can only wear 14k gold)
Topical anesthesia, numbing cream, antibiotic, or desensitizers
Drug Allergies. If yes, list in the space provided at the end of the form.
Have you had any of the following done in the last 30 days? Please select all that applies:
Facial cosmetic surgery
Chemical exfoliation (peels)
Laser hair removal on the face
Waxing around the area
HOME CARE. What skincare products are you currently using at home? Please select all that applies:
Please select if you are currently using or have used in the past any of the following:
Isotretinoin Accutane Treatment
Benzol Peroxide (BP)
Glycolic Acid (AHA)
Lactic Acid (AHA)
Tretinoin (Retin A)
Azelaic Acid (Azelex)
Please select all applicable activities:
Do you sunbathe or participate in outdoor activities?
Have you had direct sun exposure in the last 14 days?
Do you go in a tanning salon?
Have you tanned in a tanning booth in the last 14 days?
Do you feel your skin is sensitive?
FITZPATRICK SCALE. When exposed to sun, do you:
I. Very fair. Always burns. Cannot tan.
II. Fair. Usually burns. Sometimes tans.
III. Medium. Sometimes burns. Usually tans.
IV. Olive. Rarely burns. Tans easily.
V. Brown. Rarely burns. Tans easily.
VI. Dark Brown. Never burns. Always tans.
Please select the box if you hav or had experienced any of the following conditions:
Allergies to makeup
Cancer (list below)
High/Low blood pressure
Heart condition/Pace maker
Tendency to bleed
Tear duct plugs
Refractive eye surgery
Shortness of breath
Scar/s in the eyebrow area
Other medical conditions, skin care treatment, allergies, drug allergies, and any other necessary information your technician should know before the beginning of the treatment, kindly list below and explain:
I acknowledge that all the information provided by me is true and correct to the best of my knowledge.
I understand that some skin conditions may require more than 2 treatments and home care products to achieve the desired result. Results cannot be guaranteed due to individual skin types and conditions.
I understand that I will notify my PMU Artist with any changes pertaining to the above.
Select a date
Thanks for submitting!