4 Steps subbmission form STEP1 Client Name Gender MaleFemale Phone Number E-mail Address: Theraphist DOB: Select Day01020304050607080910111213141516171819202122232425262728293031 Select Month010203040506070809101112 Select Year19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 NextSTEP2 Please specify the conditions that apply to you: AcneAllergiesAsthmaAutoimmune DisorderBurnsCancerDry PatchesDiabetesEpilepsySun DamageHormonal ImbalancesHeart ConditionHirsutism (excessive hair growth)Facial or other visible scarsGrafted SkinDepression / Mental HealthPsoriasisPregnancyNomaNerve DamageSteroidal or Hormone TherapyThyroid ImbalanceVitiligo or HyperpigmentationPort Wine StainKidney DiseaseHerpes (or Cold Sores)Polycystic Ovarian SyndromeShinglesLupusOther BackNextSTEP3 Are you currently taking any medication, including painkillers/antihistamines? YesNo Please select if you are currently taking any of the below: TetracyclineActrimHydrochlorlthiazide Are you taking any medication causing sensitivity when exposed to the sun? YesNo Please circle if you have ever used or are currently using any of the below: Retin AAccutaneAlpha HydroxylGlycolic Acid Have you ever had a clinical peel? YesNo Have you had any laser or IPL treatments in the last 6 months? YesNo How would you best describe your skin. Please select: OilyOily to NormalNormalDryNormal to DryDrySensitive Do you have any implants, including dental implants? YesNo Do you have any tattoos or semi-permanent make-up? YesNo Have you ever been treated by an endocrinologist? YesNo Do you have any particular skin sensitivities? YesNo Have you had any large or small surgeries performed in the last 3 months? YesNo For women, when was the last day of your period? BackSTEP4 Back
