PLEASE FILL OUT AND BRING WITH YOU

BOMA BEAUTIFUL, LLC  SKIN CARE MEDICAL HISTORY FORM                         
                
PATIENT NAME:_________________________________________________  AGE: _______   DATE:_________________________  PHONE:_________________________          

ADDRESS: ____________________________________________________________________________                                                         Street                                                 City                       State                      Zip
                           
EMERGENCY CONTACT : _______________________PHONE:________________________        
RELATIONSHIP: _______________________________________                                
REFERRED BY: ____________________________________________________________________________                                
SKIN CARE GOAL?: ____________________________________________________________________________                                
PERSONAL HISTORY:                    
Within the last year, have you been under the care of a dermatologist?                              YES ____     NO ____
Within the last nine months, have you undergone any surgery?                             YES ____     NO ____
Have you had any of these health problems in the past or present?                             YES ____     NO ____
___HIV/AIDS     ___Diabetes     ___Epilepsy     ___Hormone Imbalance ___Thyroid Condition         ___ Immune Disorder    
___Blood Disorder ___Systemic Disease ___Hepatitis B or C ___Skin Diseases ___ Cancer
Other: __________________________________                                
List any medications, supplements, vitamins, etc., that you take regularly:                                 
____________________________________________________________________________                                
Do you smoke?  YES ____     NO _____

Do you have any special skin problems pertaining to your face?                             YES ____     NO _____
If yes, please list: ____________________________________________________________________________                            
Do you wear contact lenses?     YES ____     NO _____
What skin care products are you currently using? _______________________________________________________                                
Have you had chemical peels, laser procedures or microdermabrasion?                              YES ____     NO _____
Do you use Retin A, Renova, Accutane or Adapalene?                             YES ____     NO _____
Most recent date: _______________                                
Do you use any acne medicine (prescription or OTC)?                              YES ____     NO _____
Most recent date: _______________                                
Are you currently using any products with the following ingredients?                  ___Vitamin A Derivatives         
____Glycolic Acid         ___Exfoliating Scrubs         ___ Lactic Acid         __Hydroxy Acid        
Do you burn easily in moderate sunlight?                              YES ____     NO _____
Do you blush easily when nervous?                              YES ____     NO _____
What is your pain threshold?  ___Low     ___Medium     ___High            
Have you ever had a reaction to any of the following?:                        ___Soap     ___ Cosmetics     ___Medicine     ___Food
___Iodine     ___Pollen      ___Latex     ___Pigment    
___ Sunscreen
___Hydroxy Acids         ___Fragrance    
___Animals         OTHER: ________________________________________                        
Are you susceptible to cold sores or fever blisters?                              YES ____     NO _____
Are you susceptible to scarring (keloids)?      YES ____     NO _____
Do you have any known allergies to medications or any other substance? If so, list: ___________________________________________________________________                                

I HAVE ANSWERED THE ABOVE QUESTIONS ACCURATELY TO THE BEST OF MY KNOWLEDGE.                                 

SIGNATURE: ______________________________________ DATE: _______________