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PRIVATE PRACTIcE NO WALK-INS BY APPOINTMENT ONLY

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Health Intake

Please fill out the following form
to accurately assess your skin health and whole-person wellness.

First name

Physician's Name

Emergency Contact

Are you suffering from a medical condition, illness, or injury? *

No

Yes

Have you been hospitalized in the last 12 months? *

No

Yes

Have you ever had skin cancer? *

No

Yes

Have you ever had any fillers, Botox, other cosmetic procedures/surgeries? *

No

Yes

When was your last facial or chemical peel?

Have you had any of these health conditions in the past or present? * Required

Cancer

Hormone Imbalance

Thyroid Condition

Hysterectomy

Systemic Disease

Immune Disorders

Lupus

Heart Problems

Varicose Veins

Phlebitis/Blood Clots

Poor Circulation

Blood Clotting Problems

High Blood Pressure

Headaches (Chronic)

Spinal Injury

Metal Bone/Plates/Pins

Pacemaker

Diabetes

Arthritis

Eczema

Keloid Scarring

Skin Disease

Skin Lesions

Epilepsy

Seizure Disorder

Fever Blisters

Cold Sores

Herpes

Hepatitis

Psychological Treatment

Insomnia

Any Active Infection

Wear Contact Lens

Suffer From Claustrophobia

Sinus Problems

NONE

Last name

Physician's Phone

Emergency Phone

If you answered yes to any question, please elaborate

If you answered yes to any question, please elaborate

If you answered yes to any question, please elaborate

If you answered yes to any question, please elaborate

Please describe your best and worst facial experience!

If you answered yes to any health conditions, please elaborate.

Has your physician discussed concerns about raising your body temperature? *

No

Yes

Please elaborate

List any medications you take regularly, including vitamins/herbal supplements/Aspirin, etc. or answer "none".

List any medications you are currently taking but don’t take regularly, or answer "none

List any allergies you have, or answer "none".

List any reactions you have had to any skincare treatments and/or beauty products, or answer "none".

Do you smoke or vape any substances? *

No

Yes

Which substances?

Do you drink alcohol? *

No

Yes

How often?

Do you follow a restricted diet? *

No

Yes

If yes, please specify.

Do you exercise regularly? *

No

Yes

If yes, how often?

What is your stress level? *

Low

Moderate

Hight

Please specify.

Do you drink water daily? *

No

Yes

How much?

Do you use Retin A, Retinol, Renova, Defferin, Adaplane, Glycolic, Salicylic or any other acids or exfoliators? *

No

Yes

Please specify.

Have you been on Accutane in the past year? *

No

Yes

If yes, when was last use?

Have you been on any skin prescriptions in the past year? *

No

Yes

Please specify and date of last use?

Have you been exposed to a self-tanner/tanning bed/excessive sun/been sunburned in the past 7 days? *

No

Yes

Please specify.

How often?

Have you experienced Hyperpigmentation (darkening of skin) or Hypopigmentation (lightening) or any marks after physical skin trauma? *

No

Yes

Please specify.

Please list the brands of home care products you are currently using and how often you use them.

Cleanser

Scrub

Eye Products

Serum

Moisturizer

Nighttime Repair

Exfoliant

Mask

Sun Protection

How often?

How often?

How often?

How often?

How often?

How often?

How often?

How often?

How often?

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

The Company

Address

Phoenix, NY 13135

(7 mins. from Baldwinsville, 12 mins. from Liverpool, 17 mins. from Camillus, 20 mins. from Syracuse)

Operation Hours

Monday CLOSED

Tuesday - Thursday
9 AM - 6:30 PM

Friday

9 AM - 4:00 PM

Phone

315-529-9200

Info

Returns & Refunds

Terms & Conditions

© 2023 by Modern Age Aesthetics & Wellness

Email

Info@ModernAgeAesthetics.com

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