Client Intake Form Name(Required) First Last Phone(Required)Email(Required) Sex Assigned at Birth(Required) Male Female Address(Required) Street Address Unit or Appartment City Province Postal Code Date of Birth(Required) MM slash DD slash YYYY Were you referred to Fade Aesthetics by someone?(Required) Yes No Referred ByTreatment Type(Required)---Please Select---Laser Tatoo RemovalDark Spot RemovalRejuvenationStretch Mark ReductionScar ReductionFitzpatrick Skin Type(Required) Type 1 Type 3 Type 5 Type 2 Type 4 Type 6 Ethnicity(Required)Last exposed to UV - (Sun or tanning bed)(Required) MM slash DD slash YYYY Are you Actively Sun Tanning?(Required) Yes No Do you use self-tanning lotion?(Required) Yes No Medical History(Required) None Pace Maker / Defibrillator Metal Implants Current or History of Skin Cancer / Other Cancer / Pre-Malignant Moles Pregnancy & Nursing Impaired Immune System Diseases Stimulated by Light (e.g. Lupus, Porphyeria, Epilepsy) Diseases Stimulated by Heat (e.g. Herpes Simplex) Endocrine Disorders (e.g. Diabetes, PCO) Surgical Procedures Within the Last 3 Months Injections / Fillers History of Bleeding Disorders Facial Laser Resurfacing (Last 3 Months) Deep Checmical Peeling (Last 3 Months) Use of Medication or Herbs that induce Photo-Snesitivity Tanned Skin Skin Disorders (e.g. Keloids, Abnormal Would Healing) Active Skin Infection (e.g. Psoriasis, Eczema) Have you taken any perscription Medication in the last 3 months?(Required) Yes No Does this medication fall in any of the following categories?(Required) Acne Medication Anticancer Medication Antidepressant Medication Antiepilptic, Sedative, Muscle Relaxants Antihistamines or Allergy Medication Antihypertensive Medications Antimicrobial Medication Antiparasidic medication Antipsychotic Medication Cardiovasular Medication Diuretic Medication Hypoglycemic Medication NSAIDS Medication Wholistic Medication or Ointments Oral Contraceptives None of the above Are you taking any of these specific Acne Medications which can be photosensitizing:(Required) Isotrentinoin (Accutane) Trentinoin (Retin-A) None of the Above Are you taking any of the following anticancer medications which can be photosensitizing:(Required) Chlorambucil Cyclophosphamide Dacarbazine Fluorouacil Flutamide Mercaptopurine Methotrexate Procarbazine Thioguanine Vinblastine I am not taking any of these listed drugs. Are you taking any of the following antidepressants which can be photosensitizing:(Required) Amitriptyline Amoxapine Clomipramine Doxepin Imipramine Isocarboxazid Maprotiline Phenelzine Protriptyline Trazadone Trimipramine None of the Above Are you taking any of the following Antiepileptics, sedatives, or muscle relaxers which can be photosensitizing:(Required) Carbamazepine Cyclobenzaprine Diazepam Meprobamate Phenobarbitol Phenytoin None of the Above Are you taking any of the following Antihistamines which can be photosensitizing:(Required) Azatadine Clemastine Diphenhydramine Terfenadine Tripelennamine None of the Above Are you taking any of the following Antihypertensives which can be photosensitizing:(Required) Captopril Dilitiazem Methyldopa Minoxidil Nifedipine None of the Above Are you taking any of the following Antimicrobials which can be photosensitizing:(Required) Ciprofloxacin Clofazimine Dapsone Demeclocycline Doxycycline Enoxacine Flucytosine Griseafulvin Ketoconazole Lomefloxacine Methacycline Minocycline Nalidixic acid Narfloxacin Ofloxacin Oxytetracycline Pyrazinamide Sulfa drugs (Bactrim, Septra, Tetracycline) None of the Above Are you taking any of the following Antiparasitics which can be photosensitizing:(Required) Bithionol Chloroquine Pyruvinium Pamoate Quinine Thiabendazole None of the Above Are you taking any of the following Antipsychotics which can be photosensitizing:(Required) Chlorpromazine Chlorprothixene Fluphenazine Haloperidol Perphenazine Prochlorperazine Promethazine Thioridazine Thiothixane Trifluoperazine Thioflupromazine Trimeprazine None of the Above Are you taking any of the following Cardiovascular which can be photosensitizing:(Required) Amiodarone Atenolol Captopril Diltiazem Disopyramide Nifedipine Propranolol Quinidine gluconate Quinidine sulfate Verapamil None of the Above Are you taking any of the following Diuretics which can be photosensitizing:(Required) Acetazolaminde Amiloride Bendroflumethiazide Benzthiazide Chlorothiazide Furosemide Hydrochlorothiazide Hydro flumethiazide Methyclothiazide Metalazone Polythiazide Quinethazone Trichlormethia-zide None of the Above Are you taking any of the following Hypoglycemics which can be photosensitizing:(Required) Acetohexamide Chlorpropamide Glipizide Tolazamide Tolbutamide None of the Above Are you taking any of the following NSAIDS which can be photosensitizing:(Required) Diclofenac Fenoprofen Flurbiprofen Indomethacin Ketoprofen Meclofenamate Naproxen Phenylbutazone Piroxicam Sulindac None of the Above Are you taking any of the following wholistic medications of ointments which can be photosensitizing:(Required) Bergamot oil Oils of citron lavender lime sandalwood Benzocaine Clofibrate Etretinate Gold salts Hexachlorophene Lovastatin St John’s Wort Gmethylcoumarin (used in perfumes, lotions, etc) None of the Above Do you have any allergies?(Required) Yes No Please list your allergies here:(Required)Do you have any other medical conditions?(Required) Yes No Please describe any medical conditions you have here:(Required)Is there any other information not included in this form that you feel the technician should be aware of?(Required) Yes No Please explain:(Required)