Test for approval of laser treatment

Address:

Birthday:

SKIN CONDITIONS (select all that apply)

SKIN CONDITIONS (select all that apply)
SKIN CONDITIONS (select all that apply) 2

Please list your top 3 skin care concerns in order of priority:

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1
2
3
 

SUN EXPOSURE

How do you react to the sun?
Do you use sun protection?
Sun Exposure?
When were you last exposed to the sun?
Do you use tanning beds?
If yes, how often?
Do you use self tanner?

COSMETIC MEDICAL HISTORY

Are you under the care of a dermatologist?
Do you currently use, or are you presently taking this medications?
Have you had plastic surgery?
Have you had cosmetic injections?
Have you had any of the following cosmetic treatments (select all that apply):

GENERAL MEDICAL HISTORY

Do you have or ever had skin cancer?
Please select all that apply:
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LIFESTYLE

Have you had children?
How would you rate your stress level?
On average how much sleep do you get per night?
How would you rate your diet?

How much of the following do you have each day?

How often do you exercise?
Este campo es un campo de validación y debe quedar sin cambios.

A complete and accurate medical history is important to ensure that it is safe for you to receive treatment and to determine the most beneficial treatment and products. Treatment The protocol is based solely on the information provided. By pressing sendt, you understand that the The information you have provided above is to the best of your knowledge and will be confidential exclusively kept by Permanently You.