Emerge Medical & Well Spa Medical Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Birthday * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Preferred Method of Contact * Home Work Cell Would like to receive coupons for services? YesNo What Medications are you taking? (Including aspirin or any blood thinning medications and OTC Medican Do you use Glycolic products, exfoliating products, or Retin-A? YesNo Sensitivity to topical or local anesthetic? YesNo HOW DID YOU HEAR ABOUT US? If you were referred by a client, please list their name so we may send them a $10 referral coupon! Please Select Yes or No Are you pregnant? * YesNo Are you taking any herbal preparations? (St. John’s Wort) * YesNo Do you wear contact lenses? * YesNo Do you have dental fillings? Or metal pins? * YesNo History of skin cancer or atypical moles? * YesNo Any tattoos or permanent cosmetics? * YesNo Facial implants? * YesNo Please answer the following to the best of your ability When exposed to the sun without protection for about 1 hour * I. Always burns, never tansII. Always burns, sometimes tansIII. Sometimes burns, sometimes tansIV. Always tansV. Hispanic, Asian, Mediterranean, Middle Eastern, Native AmericanVI. African American When were you last exposed to the sun (including tanning booth)? Do you use tanning lotions? * YesNo Are you planning a holiday in the sun? * YesNo Previous laser, tweezing, waxing or electrolysis treatments? If so, when? Have you ever had skin resurfacing or photo rejuvenation? * YesNo Please mark if you have a history of or are currently suffering from any of the following. Explain briefly. Skin Athlete's footSkin/Toenail FungusOption 3HyperpigmentationWartsBoils/AbscessesEczemaCuts/Open Wounds/BruisesKeloid Scarring Circulatory Cardiovascular DiseaseHypotensionHypertensionOngoing FeverVaricose Veins/Clots/PlhebitisLymph EdemaHemophiliaStrokePacemakerSwelling/StiffnessOther Digestive ConstipationBloatingDiverticulitisIBSOther Nervous System SeizuresPinched NervesHerpes/ShinglesNumbness/TinglingSciaticaMultiple SclerosisOther Musculo-Skeletal Disc Injuries/SpinalBone/Joint DiseaseFibromyalgiaTendonitisBursitisBreaks/Fractures/DislocationsScoliosisOsteo-ArthritisSprains/StrainsPainHead InjuriesSpasms/CrampsJaw Pain/TMJOther Other Cancer/TumorsDiabetesDepressionDrug/Alcohol AddictionNicotine/Caffeine AddictionBreast ImplantsFacial ImplantsAcute TraumaSleep DisorderAuto Immune DisorderInfectious ConditionsSinus ProblemsAsthmaThyroid DysfunctionHepatitis A, B, CCold SoresHIV or AIDSBirth ControlKind of Birth ControlOther
