Given Name
Last Name
Address
City
Postal Code
E-mail
Phone
Have you ever had the following?
1. Current of history of cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or pre-cancerous lesions such as multiple dysplastic nevi.
YesNo
2. Any active infections.
3. Diseases, which may be stimulated by light at 515nm to 1200nm, such as history of recurrent Herpes Simplex, Systemic Lupus Erythematosus, or Porphyria.
4. Use of photosensitive medication and/or herbs that may cause sensitivity to 515nm to 1200nm light exposure, such as Isotretinoin, Tetracycline, or St. John’s Worts.
5. Immunosuppressive diseases, including AIDS and HIV infection, or use of immunosuppressive medications.
6. Patient history of Hormonal or Endocrine disorders, such as Polycystic ovary syndrome or diabetes, unless under control.
7. History of bleeding coagulopathies or use of anticoagulants.
8. History of keloid scarring.
9. Very dry skin.
10. Exposure to sun or artificial tanning during 3-4 weeks prior to treatment.
Are you pregnant?
What medications are you taking (including vitamins)?
Daily consumption of alcohol?
Any Allergies?
Are you taking any herbal preparations (St. John’s Wort, etc.)?
If Yes, list
Do you wear contact lenses?
Skin type (when exposed to the sun without protection for about an hour)
Always burns, never tans:
Always burns, sometimes tans:
Sometimes burns, sometime tans:
Always tans:
Hispanic, Asian, Mediterranean, Middle Eastern, African American?
When and were you last exposed to the sun (including tanning booth)?
Do you use chemical sun tanning lotions?
Are you planning a vacation in the sun?
Reason for visit (area to be treated)
Prior treatments (if any)
I understand the purpose for disclosing this personal health information to the person noted above.
Name
Date
Your name
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