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�� CLIENT HISTORY FORM Name: City: State: Address: Cell Phone: Zip: Date: Gender: Age: Employer/Occupation: Email: 1 YES NO Are you pregnant or nursing? 27 YES NO Do you have any prosthetic implants? 2 YES NO Have you had any alcohol in the last 24 hours? 28 YES NO Do you consume aspirin daily? 3 YES NO Have you ever had cold sores or fever blisters? 29 VES NO Are you under treatment for depression? 4 YES NO Do you have any allergies to latex? 30 YES NO Do you have any type of herpes? 5 YES NO Have you had a laser or chemical peel within 6 months? 31 YES NO Are yousensitive to petroleum-based products? 6 YES NO Have you ever had any permanent cosmetics or tattoos applied? 32 YES NO If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied? 7 YES NO Do you bruise easily for no obvious reason? 33 YES NO Are you undergoing radiation or chemotherapy treatment? 8 YES NO Do you routinely use Retin-A, glycolic or other exfoliating products? 34 YES NO Are you now or have you used the acne mediation Accutane? 9 YES NO Do you wear contact lenses? 35 YES NO Are you wearinga pacemaker? 10 YES NO Are you allergic or sensitive to any metals, for instance used forjewelry? 36 YES NO Do you take prescription drugs? 11 YES NO Do you have any problems healing? 37 YES NO Are you anemic? 12 YES NO Is your skin oily? 3g YES NO Do you have a history of skin sensitivities? 13 YES NO Do you use tobacco? If you use tobacco you may heal slower &this affects the timing on scheduling a touch up appt. 39 YES NO Do you have any medical conditions that have resulted In a medical professional requiring you to pre -medicate with an antibiotic prior to dental or other invasive pmcedures7 14 YES NO Do you have a history of allergic reactions to antibiotics? 40 YES NO Do you helve allergies to makeup? 15 YES NO Are you a diabetic? If yes, TYPE 1 OR TYPE 2 41 YES NO Do you have dry eyes? 16 YES NO Do you have any autoimmune disorders? 42 YES NO Do you intentionally ton -direct sun or tanning beg? 17 YES NO Are you sensitive or allergic to hand creams or body lotions? 43 YES NO Do you personally have an history of cancer? 18 YES NO Da you have your lips injected with filler materials? 44 VES NO Do you have a history of stroke or heart attack or cardiac valve disease? 19 YES NO Do you have Botox injections? 46 VES NO To your knowledge, are you allergic or resistant to over the counter level numbing products? 20 YES NO Do you menstruate? If yes, next cycle date: 46 YES NO Do you hypo -pigment (lack of pigment in the skin)? 2Y YES NO Doyou hyper -pigment? (Tendency to develop dark spots on the skin from wounds or sun)? 47 YES NO Are you allergic to hair dyes? 22 YES NO Do youtend to develop keloid pr hypertrophy scars? 48 YES NO Do you have glaucoma or any other eye disease? 23 VES NO Do you scar easilyfrom minor skin injuries? 49 YES NO Do you have arthritis? 24 YES NO Do you have any seizure related conditions? 50 YES NO Do you have high or low blood pressure? 25 YES NO Do you have tendencies to faint or become dizzy? 51 YES NO Do you have sinus problems? 26 YES NO Do you bleed excessively from minor cuts? 52 VES NO Do you have any type of hepatitis? If you answered YES to any questions above, use the reverse side of this form to provide an explanation. Correlateypur explanations to a specific question number. A "yes" answer does not Indicate that you are not an acceptable candidate for permanent cosmetics. It may simply be information that Is valuable [o me as your technician as each person's body is unique. It also may indicate that based on any health conditions that can 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 on the back. Client Signature: Date: