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AESTHETICS; Client History Profile Form Name Date Gender-Fo Mo Age Address City State Zip Employer/Occupation Ph-H Ph-W Ph-Cell How did you select me for your permanent cosmetic services? E-Mail Physician's Name Physician's Ph.No. 1 YES NO Are you pregnant or nursing? 27 YES NO Do you consume aspirin daily? 2 YES NO Have you had any alcohol in the last 24 hours? 28 YES NO Are you under treatment for depression`? 3 YES NO Other risk factors for blood borne pathogens9 29 YES NO Have a history of herpes infection at the procedure site9 4 YES NO Do you have any allergies to latex? 30 YES NO Are you sensitive to petroleum-based products? 5 YES NO Have you had a laser or chemical peel within 6 31 YES NO Do you have Botox injections? months? 6 YES NO Have you ever had any permanent cosmetics or 32 YES NO If you have permanent cosmetics or tattoos did you have tattoos applied? any problems with healing after they were applied? YES NO Do you bruise easily? 33 YES NO Are you undergoing radiation or chemotherapy treatment? 8 YES NO Do you routinely use Retin-A. glycolic; or other 34 YES NO Are you now,or have you ever been on the acne treatment exfoliating products? Accutane? 9 YES NO Do you wear contact lenses? 35 YES NO Do you have an implanted cardiac device(ICD) 10 YES NO Are you allergic or sensitive to any metals, for 36 YES NO Current medications9 instance,metals used for jewelry? 11 YES NO Do you have any problems healing from small 37 YES NO Are you anemic? wounds'. 12 YES NO Do you use Lasisse@ or any other eyelash growth 38 YES NO Do you have a history of skin sensitivities? product? 13 YES NO Do you use tobacco?If you use tobacco you may heal 39 YES NO Do you have any medical condition that has resulted in a slower and this affects the timing on scheduling a medical professional requiring you to pre-medicate with touch- up appointment,if applicable. an antibiotic prior to a dental or other invasive procedure? 14 YES NO History of cardiac valve disease or heart conditions 40 YES NO Do you have allergies to topical makeup? 15 YES NO Are you diabetic?If so,Type 1 or Type 2? 41 1 YES NO Do you have dry eyes? 16 YES NO Do you have any autoimmune disorders? 42 YES NO Do you intentionally tan—direct sun or tanning bed? 17 YES NO History of allergic reactions to antibioties9 43 YES NO Do you personally have any history of cancer? 18 YES NO Do you have your lips injected with filler materials? 44 YES NO Do you have a history of stroke or heart attack? 19 YES NO Do you menstruate?If yes:Next cycle date 45 YES NO Do you have problems being anesthetized for a dental procedure? 20 YES NO Do you hyperpigment? (Tendency to develop dark 46 YES NO Do you hypopigment(lack of pigment in the skin)? spots in the skin from wounds or sun) 21 YES NO Do you tend to develop keloid or hypertrophy scars? 47 YES NO Are you allergic to colorants? 22 YES NO Do you scar easily from minor skin injuries? 48 YES NO Do you have glaucoma or any other medical eye condition? 23 YES NO Do you have any seizure related conditions? 49 YES NO Do you have arthritis? L24 YES NO Do you have a tendency to faint or become dizzy? 50 YES NO Do you have high or low blood pressure'? 25 YES NO History of hemophilia or other bleeding disorders 51 YES NO Do you have sinus problems? 26 YES I NO J,Do you have prosthetic implants? 52 YES NO Have you ever been diagnosed with hepatitis? If you answered Yes to any questions above,use the space below and the reverse side of this form to provide an explanation. Correlate your explanations to a specific question number.A yes answer does not,indicate you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to me as your technician as each person's body is unique,or it may indicate that based on any health conditions that affect healing, it would be advisable or required for you to consult with your physician before proceeding.If this form has not addressed a medical condition you have,please list it below. Client Signature: Date: