Medical Questionnaire

 

Some illnesses/conditions can be affected by laser/light/heat treatments. Please see below. If you have any of the following, please let us know so we can advise you.

 

For laser hair removal, laser facials and tattoo removal:

*Previous Tattoo Removal Allergic Reaction?

*Herpes Simplex (Cold Sores)

*Systemic Lupus Erythematosus (SLE) (AKA Lupus)?

*Psoriasis (GP Letter needed)

*Other autoimmune diseases?

*Diabetes (GP Letter needed)

*Currently pregnant?

*Thyroid Disorders (GP Letter needed)

*Breast feeding?

*Epilepsy (GP Letter needed)

*Bleeding abnormalities?

*Treated with Ro-Accutane in the last 6 months?

*Blood thinning medication (Warfarin/Heparin/^Aspirin slow release Aspirin at 75mg per day or less as a prophylactic is ok)?

*Dark spots after pregnancy / skin injury?

*Keloid or very thick scarring?

*Implants/Metal Plates/Pacemaker?

*Vitiligo?

*Transplant anti-rejection drugs? (GP Letter needed)

*Rheumatoid Arthritis “Gold” Therapy?

*Currently treated for Pulmonary embolism/blood clot, Leg ulcers or Phlebitis

*Acute or chronic renal failure?

*Chemical peels/dermabrasion/laser resurfacing/facelift

*Photodynamic Therapy (PDT) for cancer within the last 6 months?

*Botox/fillers

*Chemotherapy/ Radiotherapy within the last 6 months

*Hepatitis*HIV

*Heart Disease (GP Letter needed)

*Hypertension (GP Letter needed)

*Hirsutism or PCOS

*Current infection/inflammatory condition

 

 

For Radiofrequency and cavitation treatments:

 

*Pregnancy or nursing (current only).  

*Menstruating  

*Heavy menses/bleeding.    

*Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.     

*Botox or filler in treatment area. 

*Pacemaker or internal defibrillator, implanted neuro-stimulators or another internal electric device.   

*Metal implants or other implants in the treatment area- i.e. IUD, screws, plates.     

*Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.    

 *Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV or use of    Immune suppressive medications. Active weeping acne.    

 *Continuous use of Retin A, retinol.  

 *Herpes (active).     

 *Medications such as blood thinners.    

*Skin blotches or rosacea.     

*Severe concurrent conditions such as cardiac disorders or epilepsy.    

*Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as    recurrent Herpes Simplex in the treatment area.    

*Areas of sensory impairment such as in cases of nerve lesions and neuropathies.  

*Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as    excessively/freshly tanned skin.    

 *Chemical sensitivities such as reactions to cosmetic products or perfumes. If known, please list specific.

*Offending ingredients: __________________­­­­­­­­­­­­­­­­­­­___________________________________

*Varicose veins in the treatment area.  

* History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.     

*Any surgical, invasive, ablative procedure in the treatment area before complete healing.    

*Any medical condition that might impair skin healing.     

 

Disqualifying Conditions for Cavitation & Radio Frequency Treatments

* Implants: heart pace-maker, braces, cochlear, artificial joints

*Coagulation disorder or bleeding   or any other artificial organ inside the body   tendency

*Pregnancy   Acute hernia, discopathy, spondylolysis

*Lactation  

*Migraines and Epilepsy

*Tuberculosis   Malignant Tumours

* Not feeling thermal changes   Acute infections or inflammations

*A burn or care after such a burn   Accutane and retinol

*Active cancer  

*Botox or filler in treatment area

*Severe active arthritis  

*Suppuration of soft tissues

*Active gout 

*Kidney stones

*Severe cardiovascular disease, circulation   (thrombus arterial sclerosis etc)

*Any active condition in the treatment area, such as   Herpes, sores, psoriasis, dermatitis, eczema and rash

*Epilepsy ***Cavitation***

*Thyroid disorder ***Cavitation***

o  Diabetes ***Cavitation***

o  Liver disease

o  Acne therapy using Iso-tretinoin such as Roaccutane within the last 6 months

 

 

 

 

 

 

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